Home | Patient Information Authorization FormPatient Information Authorization FormPlease 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.LayoutPatient Name *Patient NamePatient Name Patient Name Patient Name Date of Birth *Date of Birth Date of Birth Date of Birth Date of BirthI 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.LayoutName *Name *Name *Name *Name *Relationship to patientRelationship to patientRelationship to patientRelationship to patientRelationship to patientLayoutSignatureClear Signature(natural mother, father, or legal guardian)Date Submit
