I, the undersigned, hereby give my consent to the Urban Inter-Tribal Center of Texas and its Dental staff to examine, take any necessary x-rays, administer tests, prescribe therapy and perform procedures that are deemed necessary.
I realize that upon my signing the consent for treatment, I may present myself or my child for diagnoses and treatment for illness, defects, or complaints. I do hereby give my qualified consent for treatment, as necessary, at any time I/my child come(s) to the clinic.
If patient is a minor:
I certify that I am the parent/legal guardian of the aforementioned minor and have full authority to give this consent for dental treatment of such minor and that my authority to do so has not in any way been limited or removed by any court of law.
I certify that I have read and understand and accept the treatment plan presented to me.