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



  • 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.

  • Date Format: MM slash DD slash YYYY