Maile S.C. Kim DDS, Bren M. Chun DDS

642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439

808-261-5354

CONSENT/AUTHORIZATION FOR DENTAL TREATMENT OF A MINOR

Patient Name:
Date of Birth:
Phone:
Email:

It is the policy of Kim Pediatric Dentistry (Howard Y.B. Kim DDS, Inc.) that all minors be accompanied by a parent or legal guardian for their dental visits. We do understand that under certain circumstances, you would prefer another caregiver to accompany them.

All minors seeking dental treatment MUST be accompanied by a parent/legal guardian during the initial office visit. After the initial appointment, a minor may be seen for treatment only with written authorization from the parent/guardian under the conditions specified in this consent. If you need to send your child to their appointment with an adult other than yourself/legal guardian, please complete this section:

I, (parent/legal guardian) , cannot accompany my child,(child’s name) , to their appointment(s) with Kim Pediatric Dentistry.

Therefore, I give permission to:

Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:

Consent Conditions (check all that applies below):

(Please check one of the following below)

* I understand I am responsible for all charges or fees incurred and co-payments must be made at the time of service as our financial policy states. We will gladly process payments over the phone if a credit card is used.

Parent's/Guardian Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

© 2022 - American Dental Software All rights reserved.