Kim Pediatric Dentistry

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):

the consent to sign any and all forms required to give permission to Kim Pediatric Dentistry to treat the dental needs of my child,

the consent to perform: exam, x-rays, cleaning, fluoride treatment, and any other dental treatment deemed necessary by Dr. Maile Kim / Dr. Bren Chun.

the consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges),

the consent to the dental practice to discuss my child’s future dental treatment needs (i.e. treatment plans)

the consent to sign my child’s treatment plan once it has been presented by the dental staff. I understand this does not obligate me to the treatment, only that the office has informed me or my representative of the dental needs of my child,

the consent to schedule future dental visits for my child.

(Please check one of the following below)

I give permission for this person(s) to seek dental treatment for my child if attempts to contact me are unsuccessful. This permission includes all of the following conditions that I have read and checked above. This consent shall remain in effect until cancelled by me in writing.

I give permission for this person(s) to seek dental treatment for my child without having to contact me. This includes all of the following conditions that I have read and checked above. This consent shall remain in effect until cancelled by me in writing.

* 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: