Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential.

(*) indicates a required field.
Children's Name(s)*
I give permission for:
Name of Person*
Relationship to child(ren)*
to bring my child(ren) to Kids Healthy Teeth for their dental care. For new Patient appointments Parent/Guardian MUST be present. Treatment to be performed includes pediatric services (examinations, cleaning, radiographs, fluoride treatment, and restorative needs as have been already fully explained to me). By signing this form I am providing informed consent and assuming financial responsibility for my child(ren) to be treated under the care of Dr. Sheryl H. Griffith and her team.

This consent shall be effective from date to signature until revoked by parent or legal guardian.
I can be reached at (phone)
Signature of Parent or Legal Guardian
(Please use your mouse or finger on a touchscreen to sign in the box.)
Signature*
Printed Name of Parent/Guardian*
Date*
Date Format: MM slash DD slash YYYY

Dental Care Authorization for Non-Parent /Guardian

I give permission for: