Non Legal Guardian Consent

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
    •  Medications
    •  X rays
    •  Treatment Plan
    •  Billing
    •  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 ()