Dental/medical Treatment Authorization And Consent Form printable pdf download

DENTAL/MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

The following form is designed for those situations where minors are unaccompanied by either parents

or legal guardians. This “Dental/Medical Treatment Authorization and Consent Form” gives authority

to a designated adult to arrange for medical/dental care for a minor in the event of an emergency or

when the parent/guardian designates for routine care. This is extremely important, in that, dental/

medical care can not be provided to a minor without approval by the parents or legal guardians, unless

there is written consent authorizing an agent to give approval.

I, ________________________________________________, do hereby confer upon

(Name of Parent or Legal Guardian or Custodian)

__________________________________________, residing at_______________________________

(Name of Person Bringing Child(ren) for Care)

the power to consent to necessary dental/medical for the following child(ren):

1) Name:____________________________________________________ DOB:_________________

2) Name:____________________________________________________ DOB:_________________

3) Name:____________________________________________________ DOB:_________________

and on the child(ren)’s behalf do hereby state that the power to consent that I confer shall not be affected

by my subsequent disability or incapacity.

The power that I confer is specifically limited to dental/health care decision-making, and it may be

exercised only by the person named above.

The undersigned do hereby authorize Chelsea Pediatric Dentistry or such substitute as he/she may

designate as agent for the Undersigned to consent to any X Ray, anesthetic, medical, dental, or surgical

diagnosis or treatment and hospital care for the above named minor which is deemed advisable by and

to be rendered under the general or special supervision of any physician and/or surgeon, licensed under

the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether

such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or

elsewhere. The undersigned may also agree to any financial obligations on behalf of the parent/legal

guardian.

Parent or Guardian Sgnature_____________________________________ Date ________________

Address of Parent/Guardian __________________________________________________________

Home and Work Phones of Parent/Guardian_____________________________________________

Witness __________________________________________________________________________

Family Physician ___________________________________________________________________

Family Physician’s Full Address and Phone Number________________________________________

__________________________________________________________________________________

220 West 26th Street NY, NY 10001

Ph. 212.243.5437

F. 212.243.5435

Dental/medical Treatment Authorization And Consent Form