Parental Consent

This form is to be presented when the legal augardian will not be present.

Please instruct your child's caregiver or family member to bring this form with them to our office, when you, the legal guardian cannot personally bring the child (under 18 years of age) to their appointment. This form gives specific permission to treat your child when you are not present. This permission can only come from the legal guardian.

Child's First Name:

Middle Initial:

Last Name:

Legal Guardian First Name:

Middle Initial:

Last Name:

I, the legal guardian, give permission for the following person(s) to accompany my child to their orthodontic appointment:

Name(s):

This includes, but not limited to knowledge of personal information, treatment information, child's health, and any health concers that may come up.

My child may receive any x-rays needed for treatment, in my absence.

My temporary guardian may know financial information.

In case of emergency the best phone number to reach me is: