Minor Patient Consent For Treatment

Permission for informed consent for dental treatment for a minor patient.

I authorize , , aged 18 or over, to bring my minor child, , to appointments, make appointments, and consent to dental treatment and related dental services deemed necessary for my minor child. I understand that I must execute an Authorization to Release Protected Health Information/Treatment Records in order for OUCOD to discuss or disclose my child's medical information with the adult named above as part of the consent and treatment process.

This consent is effective from until I revoke it in writing.

Signature of Parent/Legal Guardian:

Date: