Dental Treatment of Minors
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Dental Treatment of Minors

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Dental Treatment of Minors Consent

All fields marked with * are required.
*Office Location
*Patient's Name:
*Birthdate:
*I give consent for myself/my child to receive dental treatment deemed necessary by the providers at the Open Door Family Medical Center. These procedures include, but are not limited to; examinations, oral prophylaxes (cleanings), fluoride treatments, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) treatments, extractions, and the use of local anesthetics. I understand that the use of local anesthetics carries a small risk for swelling, bruising, allergic reaction, changes in pain perception, or prolonged anesthesia. This consent shall be considered in effect until rescinded or revoked.
*Your Name:
*Relationship to Patient:
*Date:
*Signature:

Please sign in the box below using your mouse, touch screen, or touchpad.

Clear    Use Most Recent Signature

I accept that this is the legal representation of my signature.


This section needs to be completed for children under the age of 18 by a parent or legal guardian ONLY.


I affirm that I am the parent or legal guardian for the above named minor child. If I am unable to accompany my child, I give permission for the individuals named below to escort my child for treatments.
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
If child is over 13, please check one:
Signature of parent or legal guardian:

Please sign in the box below using your mouse, touch screen, or touchpad.

Clear    Use Most Recent Signature

I accept that this is the legal representation of my signature.

This consent shall be considered in effect until rescinded or revoked.