Pediatric Dental Patient Consent Form
Patient Information
Child's Full Name
Date of Birth
Parent/Guardian Name
Phone Number
Email Address
Medical & Dental History
Allergies
Current Medications
Medical Conditions
Previous Dental Concerns or Treatments
Consent
I hereby authorize the dental professional to perform dental procedures deemed necessary for my child:
I understand the risks and benefits explained to me.
I have had the opportunity to ask questions.
Parent/Guardian Signature
Date