Kids Stop Dental: Medical Release Special Authorization Form for Minors

Kids Stop Dental: Medical Release Special Authorization Form for Minors
I,
Enter Your Name Here
authorize the following person/persons to accompany my child/children to their dental appointments at this facility. I also authorize that the following person/persons can consent to dental treatment for my child/children by this facility.

I understand that I am responsible for services rendered for treatment and payments authorized by my personal representative(s).

I understand that I may terminate this authorization form at any time. In order to do so, I must notify this facility in writing regarding termination and effective date.
1. Name of Personal Representative*
1. Relationship to Child
2. Name of Personal Representative
2. Relationship to Child
3. Name of Personal Representative
3. Relationship to Child
4. Name of Personal Representative
4. Relationship to Child
Please list the names of all children:*
Responsible Party:*
Date*

MonthDayYear
This field is required.
Relationship to Child:*
Should be Empty: