Consent for Dental Treatment / Dental Care for Minor Children

Dr. Ross Fishman DMD, MS, PA
552 Jacksonville Drive Jacksonville Beach, FL 32250
Phone: (904)247-4097 Fax: (904)247-8495
Patient's Name*
First Last
Patient's DOB*
MM slash DD slash YYYY
Allergies we should be aware of:
Mother's Phone
Mother's Email
Father's Phone
Father's Email
Parent or Legal Guardian Name*
First Last
I do hereby consent to any dental care/treatment determined necessary by Dr. Ross Fishman/Fishman Pediatric Dentistry.
I understand that I will be financially responsible for any dental care/treatment provide by Dr. Fishman and/or staff.
Parent or Legal Guardian Signature*
Date*
MM slash DD slash YYYY
Authorization*
I authorize the transaction and charge of my Credit Card for today's visit in my absence.
Name on the card*
First Last
Card Type*
Card Number*
Exp Mm*
Please enter a number from 01 to 12.
Exp Yy*
Please enter a number from 20 to 35.
V-code*
Please enter a number from 000 to 9999.