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.