request and authorize the "PRACTICE" and its personnel and/or affiliates to deliver routine dental care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that the adult presenting my child is responsible for payment of any insurance co-payments or deductibles at the time of service and I am responsible for any/all remaining balance(s). I confirm that I have provided an accurate and current medical history for my child which includes medical conditions, medication allergies, and a list of current medications. I understand the practice personnel my contact me to confirm medical information prior to beginning any treatment. I give my authorization for all dental treatment including routine procedures that may be required during my absence to include but are not limited to x-rays, examinations, preventive procedures such as cleanings, fluoride and sealants, and emergency dental treatment such as extractions.