CAREGIVER CONSENT FORM FOR TREATMENT OF A MINOR

It is the policy of Mountain View Pediatric Dentistry that all minors be accompanied by a parent or legal guardian for their dental visits. We understand, however, that there may be times when you prefer another caregiver to accompany them.

A parent or guardian MUST be present for your first visit with our office. After this initial appointment, a minor may be seen for routine six-month check-ups and cleanings if brought by another caregiver. That person may be a babysitter, older sibling or other family member and must be 18 years or older. If we do not have this consent on file, except in emergency situations, we reserve the right to reschedule your child’s appointment. If this caregiver has Power of Attorney and/or legal decision making rights for your child please bring that documentation to your child’s appointment so that we have it on file.

I, the undersigned, as the parent or legal guardian hereby authorize the below named caregiver(s) to be present for my child’s routine dental visits:

In the event of any issues or concerns, I understand that a reasonable attempt will be made to contact a parent or legal guardian. However, if I’m not available, I authorize the above person to make the necessary decisions on my behalf.