Dover Kids Teeth

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YOUR CHILD/CHILDREN

First Name *

Middle Initial

Last Name *

Suffix

Date of Birth *

I do hereby grant permission for Dover Pediatric Dentistry to disclose my child(ren)'s health information to the following personal representative(s) *

Relationship

First Name *

Middle Initial

Last Name *

Suffix

please elaborate *

Information to be disclosed (please check): *

	Appointment dates and times
	Treatment plans and referrals
	Financial and billing information
	Any other pertinent dental health information related to treatment at this office.
	None of the above

I understand that this permission will remain in effect unless a written cancellation has been provided to Dover Pediatric Dentistry & Orthodontics, PLLC.

Parent/Guardian Name *

Signature of Parent / Legal Guardian *

Relationship *

please elaborate *

Date

* By completing this form online, you consent that you are electronically signing it.

Monday - Thursday	8:00 AM – 5:00 PM
Friday - Sunday	Closed

HIPAA

YOUR CHILD/CHILDREN