Use this form if you are sending your child with an adult who is not your child’s parent or legal guardian and want them to communicate with us on your behalf. You can also use this form if you plan to send you minor child to visit us without an adult present.
If you are a new patient to our practice or have not visited in more than two years, you can complete this form prior to your visit to save time. This provides our Doctor and Hygienists with the important information they need to give you the best and safest care. Remember that your information shared with our staff is confidential.