Alternate representation form

*Parent consenting to alternate adult representation must be one of the parents listed on original paperwork for the patient. If you have a question about who is listed on your child’s original paperwork, please call our office for details.

Date of Appointment*

Patient Name*

First Last

Parent Name*

First Last

Parent Email Address on file at Smile Wonders*

Alternate Responsible Party Name*

First Last

Acknowledgment and Approval*

I, the parent of [the patient listed above], request Smile Wonders, PLLC to accept consent to treat by [Alternative Responsible Party (ARP) listed above] in my absence. They may consent to treatment for treatment recommeded by the team and doctors of Smile Wonders PLLC including but not limited to professional cleaning, fluoride treatment, any necessary x-rays, restorative treatment (fillings, nerve treatments, tooth colored or stainless steel crowns/caps, extractions, sealants, soft tissue surgery (frenectomy, frenuloplasty, drainage of an infected tooth, gingival recontouring), trauma treatment, as applicable.

I understand that the ARP accompanying my child to Smile Wonders will be required to submit payment for services rendered (or a portion thereof if in-network or PPO insurance plan is on file). I understand that I may choose to keep a credit card number on file for this circumstance and it will be charged on dates of service where I am not present when the above named person is attending dental appointments with my child(ren). If I do not have a credit card on file, I understand that the above named person will be responsible for any payment necessary at Smile Wonders.

I understand that I am able to remotely participate during the appointment as long as the ARP is able to reach me via phone or video call while the appointment is in progress. If I cannot be reached during the scheduled appointment, and I am interested in discussing any findings, recommended treatment or any oral hygiene instructions, I understand that I can request to schedule a teledentistry office visit appointment with the doctor.

On the same note, if I cannot be reached during the scheduled appointment, and there are any significant/concerning pathological findings or treatment recommendations, the pediatric dentists at Smile Wonders may request that a seperate teledentistry office visit appointment is scheduled at a time convenient to me and the doctors so that discussion and planning for the treatment needed.

I understand that in most cases a seperate appointment may not be necessary as parents can be reached during the scheduled appointment. However, if for either of the reasons listed above, a teledentistry office visit is required, there will be additional fees applicable.