• Consent to provide preventive services to a minor child in the absence of their parent or legal guardian.

  • 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.

  • 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.

  • Date Format: MM slash DD slash YYYY