Parental Release Form - Southern Dental Associates
Parental Release Form
We understand that sometimes it may be difficult to get time off work to bring your
child to their dental appointment. Because of this, it sometimes becomes necessary for
parents to send a family member or friend with the child. Due to the fact that they are
not the child¡¯s legal guardians, they need to be authorized by you to consent to dental
treatment for your child.
I_______________________________________________________ hereby authorize
(Parent/legal guardian)
_______________________________________________________ to bring my child
(Responsible party)
____________________________________________________ to his/her dental visits.
(Child¡¯s name)
I AUTHORIZE the above responsible party to make decisions regarding treatment for
my child.
I understand that sending my child with someone else does not in any way relieve me
of my financial responsibilities for treatment on that day. I also understand that a
change in the treatment plan will also change the amount for treatment on this day,
and is expected at the time of service. The responsible party should be made aware of
this before agreeing to bring your child. They will be responsible for payment at the
time of service.
________________________________________
Signature of parent/legal guardian
____________________
Date
................
................
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