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