Complete only if you want to authorize someone other than a parent or legal guardian to schedule or authorize treatment.
I certify that I am a parent or legal guardian and have authorization to make health care decisions for this child. By signing below, I give permission for the person listed here to schedule and authorize appointment(s) and treatment(s), without my informed consent, for any dental services. I understand that I am responsible for any charges that may occur from such treatment. I understand this authorization will expire one year after signing or sooner if noted below. I further understand I can withdraw this consent at any time and all withdrawals must be submitted in writing.