Thank you for answering these important questions. They will help us to understand your child and your concerns. Because your child is a minor, it is necessary to obtain signed permission from a parent or legal guardian. No treatment will be initiated until the individual responsible for the child acknowledges understanding and acceptance of treatment and associated fees. I certify that the statements completed on this form are true and correct to the best of my knowledge. I will not hold the dentist or any member of his or her staff responsible for any action they take or do not take because of errors or omissions that I have made in completing this form. I hereby authorize the dentist and staff to provide any necessary dental services my child may need. Name of Person Completing Form: Relationship to Child: