I, being the parent/legal guardian of authorize to seek, obtain and consent to routine dental check-ups, non-invasive/reversible dental treatment, and emergency dental treatment for as deemed necessary by a licensed medical or healthcare professional.
I authorize the following information to be used or disclosed to () regarding my child, .
- Dental Records
- Health History
- X rays
- Treatment Plan
- Or all of the above
I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my child’s protected health information.
This authorization is for the time period when my child is in the care of ()