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*

Patient Name*

First Last

Parent Name*

First Last

Parent Email*

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 Party Responsible listed] above in my absence. They may consent to treatment for any routine 6 month appointments (professional cleaning, fluoride treatment, any necessary x-rays), restorative treatment (fillings, extractions, sealants, etc), soft tissue surgery (frenectomy, gingival recontouring, etc) as treatment planned by a pediatric dentist of Smile Wonders. I understand that the person visiting 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 as Smile Wonders.