Parental Rights Policy Online Form Palm Bay Location

Parental Rights Online Form
Our office policy is to show proper documentation of guardianship/legal custody which therefore gives the right to the legal guardian the ability to make major decisions for the child's health and well being.
In the event that you being the parent or legal guardian can not bring child to their dental appointment, you will need to give permission in writing to the office.
(Parent Name) I
First Name*
, give permission to the following people to bring
(Child's Name)
Child Name*
to their dental appointments and make all the appropriate decisions on my behalf.
1.
2.
3.
4.
5.
Please sign below to indicate you have read and understand our parental rights policy
Signature:*
Date
Month
Day
Year
6050 BABCOCK ST. SUITE NO.2, PALM BAY, FL, 32909 | PHONE: 321-725-9946

Parental Rights Online Form