Treatment Consent Form without a Parent


Philadelphia Residents Consent Form

I, , give Best Dentist 4 Kids LLC permission to

Treat my child, , while I am not present.

The individual bringing my child to the appointment is named, and is at least eighteen

Years of age and is the patient's .

I also give this individual permission to make decisions regarding my child's dental treatment, medical treatment (if necessary should as emergency arise) and behavior management. I understand payment is expected at the time of treatment.

Parental contact information for questions regarding treatment of the child:

Parent's Name *

Please fill out this mandatory field.
Contact Info: (Cell) *

Please fill out this mandatory field.
(Home)

Invalid Input
(Work)

Invalid Input
Mailing Address *

Please fill out this mandatory field.
City *

Please fill out this mandatory field.
State *

Please fill out this mandatory field.
Zip Code *

Please fill out this mandatory field.
Relationship to Patient *

Please fill out this mandatory field.
Signature (use finger or mouse to sign) *

Please include your signature.

Please complete the CAPTCHA.


Hatboro Residents Consent Form

I, , give Best Dentist 4 Kids LLC permission to

Treat my child, , while I am not present.

The individual bringing my child to the appointment is named, and is at least eighteen

Years of age and is the patient's .

I also give this individual permission to make decisions regarding my child's dental treatment, medical treatment (if necessary should as emergency arise) and behavior management. I understand payment is expected at the time of treatment.

Parental contact information for questions regarding treatment of the child:

Parent's Name *

Please fill out this mandatory field.
Contact Info: (Cell) *

Please fill out this mandatory field.
(Home)

Invalid Input
(Work)

Invalid Input
Mailing Address *

Please fill out this mandatory field.
City *

Please fill out this mandatory field.
State *

Please fill out this mandatory field.
Zip Code *

Please fill out this mandatory field.
Relationship to Patient *

Please fill out this mandatory field.
Signature (use finger or mouse to sign) *

Please include your signature.

Please complete the CAPTCHA.