Patient Information Authorization Form | Kids Dental Experts

Patient Information Authorization 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.

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.

(natural mother, father, or legal guardian)
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