Parental Consent Form

At My Friend’s Dentist, we understand that from time to time you may not be able to bring your child to their dental appointment. We will treat your child without you present for any and all dental procedures provided that:

1. The child is 16 years old or older.
2. The parent/legal guardian has signed all required documentation.
3. The parent/legal guardian has informed our office that they will not be present during the appointment before the child comes into their appointment.

Today's Date *

Month Day Year

Parent/Guardian's Name *

First Name Last Name

Child's Name *

First Name Last Name

Child's Date of Birth *

Month Day Year

Child's Allergies *

If none, please type 'None'

Child's Current Medications *

If none, please type 'None'

Child's Chronic Conditions *

If none, please type 'None'

Identify any specific limitations on the kinds of dental services/treatment for which this authorization is given. If none, please type 'None'.

Limitations *

If none, please type 'None'

I have the legal right to preauthorize My Friend’s Dentist and its personnel to deliver routine dental treatment and services to my child, listed above, even if I am not in the operatory during treatment. Routine dental care may include, but is not limited to: dental examinations, prophylaxis (cleaning), fluoride treatment, x-rays and any other treatment plans previously discussed and agreed upon by the parents/legal guardian.

I request and authorize My Friend’s Dentist and its personnel 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 understand and agree that the electronic signatures and dates on this form will not expire without written notice or when a minor becomes the age of 18 and that a photocopy of this form is considered valid as the original.

Signature *