Minor Consent Form

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.

This consent is to be effective

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:

do authorize the release of information to the following persons:

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!