Patient Information Authorization Form | Kids Dental Experts

Patient Information Authorization Form

Please enable JavaScript in your browser to complete this form.

This form is to be completed for any person in addition to the natural mother, father, or legal guardian that may bring your child/children in for their dental appointments. This authorization will remain in effect until it is revoked in writing by the natural mother, father, or legal guardian.

Date of Birth
Date of Birth
Date of Birth
Date of Birth
Date of Birth

I hereby authorize Kids Dental Experts® to release and discuss all information regarding dental visits to the individuals listed below, and these individuals may consent to dental treatment for all patients listed above.

Clear Signature
(natural mother, father, or legal guardian)
Date
© 2025 Kids Dental Experts, All Rights Reserved