Permission to Treat a Minor

Permission to Treat a Minor

Use this form to provide MyOrthodontist with authorization to treat your minor.

  • Who can be contacted in case of emergency?
  • Authorization

    By submitting this form I give permission to my child to attend his/her regular orthodontic/dental appointments alone without my presence and authorize treatment for my child in accordance with the office policy of MyOrthodontist. This includes providing a history of present treatment, the disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays and coinsurance.

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