Dental-Consent for Another Form

212 S. 4th Street Suite 101 Grand Forks, ND 58201

Designation of Another Person to be present for Dental Care
I, (parent/legal guardian) Parent/ Legal Guardian* , cannot accompany my child,
(child's name) Child's Name* , to Spectra Health’s Dental Clinic.
Therefore, I give permission to (person's name- over 18yrs & relationship) as follows:
(1)*
Last, First Name & Relationship to Child
(2)
Last, First Name & Relationship to Child
(3)
Last, First Name & Relationship to Child
(3)
Last, First Name & Relationship to Child
(Check all that apply):

I understand that treatment will be completed as listed on the treatment plan (example: composite/amalgam filling).I give permission for my child to receive dental treatment (including any type of operative/ filling procedures WITH Nitrous Oxide) and provide consent for such treatment if attempts to contact me are unsuccessful.I give permission for my child to receive dental treatment (including any type of operative/filling procedures WITH Nitrous Oxide) and provide consent for such treatment without having to contact me.I understand that I need to be present for all extraction appointments or come in if otherwise requested by the provider.
Expiration of Permission (check all that apply):

This form will remain in effect until revoked by a letter in writing.This form is valid for one year:
Effective date

MonthDayYear
Date
Expiration date

MonthDayYear
Date
(Signature of parent or legal guardian)

Clear
Date *

MonthDayYear
Date
Time of signature*

Hour Minutes

AM/PM Option
Address (parent)
Home Phone
Work Phone
Should be Empty: