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

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

M	8am - 5pm
T	8am - 5pm
W	8am - 5pm
T	8am - 3pm
F	By Appointment Only
S	Closed
S	Closed