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Parent / Legal Guardian
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Minor
*
Child
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Authorized Person(s)
Name
*
First Name
Relationship to Child
Authorization
I hereby give my authorization and consent for the named authorized person(s) to consent to the medical / dental care and treatment of my child. I hereby authorize and grant that the named person(s) has / have permission to sign for any medical / dental procedures or treatments deemed necessary for the well-being of my child.
I am, by this document, representing that I have the authority to consent for all medical / dental care and treatment of said child.
Signature of Parent / Legal Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: