Permission to Treat (Newborn to 17 years)

NOTE: The July 2020 revised version will need to be completed by all patients, even if a prior version is on file. Please complete this form to notify us as to the individuals who may bring your child to the office for treatment. Without this form, we will be unable able to deliver medical service to your child if he or she is accompanied by someone other than the listed parent(s)/legal guardian.