Consent to provide preventive services to a minor child in the absence of their parent or legal guardian.I*as the parent/legal guardian of*do hereby authorize the doctors and staff of Briarwood Valley Dentistry to provide preventive dental services to my child/dependent in my absence. By providing this authorization, I assume complete responsibility for notifying the Doctors and staff, prior to treatment, of any changes in my child's/dependent's medical history.This authorization includes permission to provide the following services. Please check all that apply:* Oral Examination Diagnostic X-Rays, which may include: Bitewings- for cavities detection Periapicals- to evaluate problems with a particular tooth Cleaning Fluoride Treatment Sealants I understand that all services may not be covered by my insurance plan, and that I will be responsible for payment in full of all services rendered. This authorization will remain in force, until such time as I personally notify the doctor or clinical staff of any changes.Signature:*Date:* Date Format: MM slash DD slash YYYY
