Consent Form for Authorization of Dental Treatment

Ross Fishman, DMD, MS
552 Jacksonville Drive Jacksonville Beach, FL 32250
Phone: (904)247-4097 Fax: (904)247-8495
Parent/Guardian Name*
First Last
Designee Name*
First Last
Designee's Relationship to patient*
Designee Phone*
Patient Name*
First Last
Patient Name
First Last
Patient Name
First Last
Patient Name
First Last
I give permission for the designee listed above to authorize treatment and procedures for my child/children in my absence. I will be financially responsible for the dental care provided. This consent will serve for a period of one year from the date signed.
Parent's Signature*
Date*
MM slash DD slash YYYY

Copyright © 2023. All rights reserved | Support by Gifted Owl.