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Post on 23-Jun-2020
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Lakeside Family Dentistry 13402 Summerport Village Pkwy., Ste. 502
Windermere, FL 34786 Ph: (407) 656-8545 Fax: (407) 656-9702
Informed Consent for Extraction
Permission for Dental Examination and /or Treatment of a Minor
I am the parent or legal guardian of _____________________________________, who is a minor child and I do hereby authorize and consent to any radiographs, examination, anesthetic, sedative or dental treatment rendered under general, direct or indirect supervision of Dr. __________________________ and his/her associates, staff members or agents, as he/she may deem necessary. This authorization will remain in effect until cancelled in writing by me.
_____________________________________ ________________________________________ Patient’s Name (Please Print) Patient’s Signature _____________________________________ Date _____________________________________ Representative of Lakeside Family Dentistry
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