Minor Consent Form

I, as the parent/guardian of

a minor child, voluntarily delegate my legal authority to basic dental care (exam, routine annual x-rays, routine fluoride treatment, cleaning, and oral hygiene instruction) on behalf of my minor child to: Holland Family Dentistry | 545 Michigan Ave, Holland, MI 49423 | (616) 396-1058.

The consent is to be exercised in good faith and in my child’s best interest, subject to the following conditions (if any):

This consent is to be effective

from

or otherwise for the period of time, which I will not be reasonably available to make such decisions for my child.

do authorize the following named individual(s) authority to make dental care decisions for the above mentioned minor in my absence:

Name

Relationship to patient:

Name

Relationship to patient:

do authorize the release of information to the following persons:

Name

Relationship to patient:

Name

Relationship to patient:

Parent/Guardian Name

Today's Date

Phone number in case of emergency

Patient Forms

Select and fill out the forms below before your next visit to Holland Family Dentistry in Holland.

We like to make things easy for our patients, which is why we have provided fillable online forms. To save you time on your next visit to our Holland dental office, feel free to select and fill out the appropriate forms below. We look forward to seeing you soon.

Patient Registration Form

Health History Form

Minor Consent Form

Financial & Privacy Policies Form

Cancel/No Show Policy

HOLLAND FAMILY DENTISTRY OFFERS A NUMBER OF COSMETIC, PREVENTATIVE, GENERAL, AND SPECIALIZED DENTAL SERVICES AT OUR OFFICE IN HOLLAND.

Learn more about the services we offer and the conditions we treat by reading on and scheduling an appointment!

MAKE APPOINTMENT

OR GIVE US A CALL AT
(616) 396-1058

Monday	8am - 4pm
Tuesday	8am - 4pm
Wednesday	8am - 4pm
Thursday	8am - 3pm
Friday	Closed
Saturday	Closed
Sunday	Closed