Consent and Assignment for the Treatment of a Minor
The undersigned hereby authorizes Dr. Amna Shebani and Associates (Dentistry for Children) to perform the examination and, after explanation, the necessary dental services and those methods she deems appropriate in her professional judgment for the care of the above-named child. This authorization includes the release of my child’s medical records if deemed necessary for the proper care of my child. I further authorize that my insurance benefits be paid directly to the dentist and understand that I am financially responsible to the dentist for all the charges not covered by my insurance. The consent shall remain in full force and effect until cancelled by either party.
Relationship to Child
2. Is child receiving any medication or drugs?
12. Is your child adopted?
Does he/she know?
HAS YOUR CHILD HAD ANY HISTORY OF, OR DIFFICULTY WITH ANY OF THE FOLLOWING?
Please describe any current medical treatment including drugs, pending surgery, recent injuries or any other information I should be aware of that we have
I CERTIFY THAT I AM THE DULY AUTHORIZED AGENT OF THE PATIENT AND THAT I HAVE READ AND I UNDERSTAND THE ABOVE
QUESTIONS. I WILL NOT HOLD DR. AMNA SHEBANI OR HER ASSOCIATES, OR ANY MEMBER OF HER STAFF, RESPONSIBLE FOR ANY
ERRORS OR OMMISIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.
RELATIONSHIP TO CHILD