Consent and Cancellations - Fishman Pediatric Dentistry

Child's Name*
First Last
Child's Name
First Last
Child's Name
First Last
Child's Name
First Last
Consent

I hereby grant authority to Dr. Fishman and his legally qualified auxiliaries to utilize x-rays, anesthetics, pre-medications, preventive and restorative procedures as may be necessary or advisable in the diagnosis and treatment of my child’s dental condition. I understand that I will be consulted before any treatment is rendered.
Parent's Signature*
Date*
MM slash DD slash YYYY
Cancellations

I understand that a minimum of 24-hour notice is required to cancel or change a dental appointment. I also understand that a $60.00 broken appointment fee will be applied to my account if the cancellation occurs without a 24-hour notice. I agree to remit the fee within one week, and no further appointments will be rescheduled until the balance is cleared. I also recognize that our office will consider waiving the fee if the broken appointment is a result of a sickness.
Parent's Signature*
Date*
MM slash DD slash YYYY