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CONSENT FOR DENTAL TREATMENT OF A MINOR (LIMITED POWER OF ATTORNEY)

Dentistry for Children in Highland

I(we) the undersigned parent, parents, or legal guardian of*

, A minor, do hereby authorize and consent to any medical exam or treatment rendered under the general or special supervision of Kurt Halum, DMD, a duly licensed dentist, licensed under the provisions of the laws in the state of Indiana. It is understood that this authorization is given in advance of any specific diagnosis, treatment or dental care being required but is given to provide authority and power to render care, which the aforementioned dentist in the exercise of this best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that a ny of the a bove treatment will not be withheld if the undersigned cannot be reached.

Signature
 
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(Your IP Address : )

This consent shall remain effective until the minor can legally consent for themselves, is discharged from the above practice or is revoked in writing by the minors' Parent or Legal Guardian.

The following people may present the minor child for treatment:

Medical Information

Telephone number where parents or legal guardian can be reached:

Thank you for visiting Kurt Halum Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form

CONSENT FOR DENTAL TREATMENT OF A MINOR (LIMITED POWER OF ATTORNEY)

Dentistry for Children in Highland

I(we) the undersigned parent, parents, or legal guardian of , A minor, do hereby authorize and consent to any medical exam or treatment rendered under the general or special supervision of Kurt Halum, DMD, a duly licensed dentist, licensed under the provisions of the laws in the state of Indiana. It is understood that this authorization is given in adva nce of any specific diagnosis, treatment or dental care being required but is given to provide authority and power to render care, which the aforeme ntioned dentist in the exercise of this best judgment may deem advisable. It is understood that effort sha ll be made to contact the undersigned prior to rendering treatment to the patient, but that a ny of the a bove treatment will not be withheld if the undersigned cannot be reached.

List any restrictions:
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

This consent shall remain effective until the minor can legally consent for themselves, is discharged from the above practice or is revoked in writing by the minors' Parent or Legal Guardian.

The following people may present the minor child for treatment:
Name:
Relationship to Minor:
Name:
Relationship to Minor:

Medical Information

Birth Date:
Allergies:
Any special medications or pertinent information:

Telephone number where parents or legal guardian can be reached:

Name:
Best Phone Number:
Name:
Best Phone Number:
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