Patient Information Authorization Form | Kids Dental Experts

(920) 592-8940 Green Bay | De Pere Appointment Request

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.

Patient Name

Patient Name

Patient Name

Patient Name

Patient Name

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.

Name

Name

Name

Name

Name

Relationship to patient

Relationship to patient

Relationship to patient

Relationship to patient

Relationship to patient

Signature

Clear Signature

(natural mother, father, or legal guardian)

Date

© 2025 Kids Dental Experts, All Rights Reserved

HIPAA Privacy Policy | Blog | Disclaimer