Designation of Consent for Another to Authorize Treatment

Designation of Consent for Another to Authorize Treatment

Spectra Health Dental Clinic
It is best practice to see minors with their parent or authorized guardian present. If you cannot be present at the appointment with your minor, we are legally obligated to have your written authorization before we treat your minor.

This form allows you to pre-designate adults that can accompany your minor at future visits and consent to treatment for your minor by exercising their own best judgement upon advice of Spectra Health licensed personnel.

Our clinic staff and providers reserve the right to postpone any non-urgent procedure if proper consent cannot be obtained before the time of an appointment.
PART I - Minor Patient and Legal Guardian Information

NOTICE: This form MUST be completed by the minor patient's parent or legal guardian.
Minor Patient's Name

Minor's First NameMIMinor's Last Name
Minor Patient's Date of Birth

MonthDayYear
Date
Parent/Legal Guardian Name

Parent/ Legal Guardian First NameMIParent/ Legal Guardian Last Name
Parent/ Legal Guardian Date of Birth

MonthDayYear
Date
Relationship to Minor Patient
Date of Birth

MonthDayYear
Date
Parent or Guardian Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
The authorized guardian for this minor is a representative of a government agency:
Legal Guardian - Government Agency
Government Agency Phone Number
Format: (000) 000-0000.
Add an additional parent or legal guardian to this authorization?
Additional Parent/ Legal Guardian Name

First NameMILast Name
Relationship to Minor Patient
Parent or Guardian Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Part II - Designation of adult who can accompany minor patient to appointments

Minors under 14 years of age must be accompanied to appointments by a parent, authorized guardian, or designated adult.

In this section of the form, you may designate any other adults who can accompany the minor patient to an appointment. These individuals will be able to authorize treatment on your behalf.

The authorized individuals must be over the age of 18.
1. Name of adult authorized to accompany your minor to appointments at Spectra Health

First NameLast Name
1. Relationship to minor
1. Can accompany minor to visit?
1. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?
2. Name of adult authorized to accompany your minor to appointments at Spectra Health

First NameLast Name
2. Relationship to minor
2.Can accompany minor to visit?
2.Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?
3. Name of adult authorized to accompany your minor to appointments at Spectra Health

First NameLast Name
3. Relationship to minor
3. Can accompany minor to visit?
3. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you wish to add another authorized adult to accompany your minor to appointments at Spectra Health?
4. Name of adult authorized to accompany your minor to appointments at Spectra Health

First NameLast Name
4. Relationship to minor
4. Can accompany minor to visit?
4. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Minors over the age of 14: If your minor is over the age of 14, can they attend appointments without you, or without an approved designated adult?
- Extraction Appointments:
  
  Due to the irreversible nature of extractions, I understand that a parent or legal guardian must be present for all extraction appointments involving my minor child, and no other adult can be designated to authorize this treatment or attend these visits.
  
  Minor patients between the ages of 14 and 18 must be accompanied at these visits.
- Parent/Guardian Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- I understand that dental treatment will be completed as listed on the treatment plan I have signed separately and that a parent or legal guardian must separately authorize the dental treatment plan
- Are there any limitations you would like to place on the treatment that Spectra Health may provide to your minor if you are not present at an appointment?
- If yes please describe
- Parent / Legal Guardian Consent:
  
  In an emergency, we will provide treatment and contact you as soon as possible. Urgency will be determined by our licensed professionals. Be advised that your minor's protected health information may be shared with the person(s) you designate on this form to accompany your minor to appointments. If you do not want protected information shared with these individuals, please designate that in the limitations section above.
  
  I have the legal right to pre-authorize Spectra Health to deliver health care to my minor, listed above. I request and authorize Spectra Health and its personnel to deliver health care to my minor, listed above. I understand that every effort will be made to obtain proper consent prior to each visit. I understand that in an emergency situation, treatment for my minor will be initiated immediately and Spectra Health personnel will contact me as soon as possible. I understand that I am providing authority to the designated adult(s) to consent to treat my minor and exercise his or her own best judgement upon the advice of licensed Spectra Health personnel. The information provided on this form is true, correct, and complete to the best of my ability.
- Parent Legal Guardian Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- Parent Legal Guardian Printed Name
- Should be Empty:

Designation of Consent for Another to Authorize Treatment

PART I - Minor Patient and Legal Guardian Information

Part II - Designation of adult who can accompany minor patient to appointments