Parental Consent for Dental Treatment

A parent or legal guardian must accompany a child younger than 18 years of age to consent for all dental treatment provided.

If a parent or legal guardian cannot accompany the child, a Parental Consent for Dental Treatment form must be completed and submitted to the dental practice.

The Parental Consent for Dental Treatment form gives a child's caregiver, who is not the parent/legal guardian, permission to consent to dental treatment for your child(ren).

Parent/Legal Guardian Full Name: *

Parent/Legal Guardian Email: *

Child 1 Full Name: *

Date of Birth: *

Child 2 Full Name:

Date of Birth:

Child 3 Full Name:

Date of Birth:

For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:

Person 1 Full Name: *

Relationship to Child(ren): *

Person 2 Full Name:

Relationship to Child(ren):

Person 3 Full Name:

Relationship to Child(ren):

I authorise the individuals named above to give consent for dental treatment on behalf of my child(ren) listed above, which may be required in my absence.

I understand that I am still financially responsible for any services provided to my child(ren) that were approved by authorized person(s).

Parent/Guardian's Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.