Get Facial Consent Forms

The consent form you sign gives the physicians and staff of Tyler Oral Facial Surgery permission to treat your child. Notice to the Parents or Legal Guardians of a Minor If your child is a minor you must be present at your child s initial visit to sign the parental consent form below and provide your child s social security number. Without a signed consent form we cannot legally treat a minor child. the course of treatment photographs may be taken for clinical or educational purposes. If you are not the parent but are the legal guardian you will need to provide legal documentation that you are the legal guardian* This information will be kept in the child s file. Minor Accompanied by others If I am unable to accompany my child to the appointment the below listed individuals have my permission accompany my child. This agreement is required in order for the unaccompanied child to be seen and treated* Initials CONSENT TO TREAT MINOR I authorize Tyler Oral Facial Surgery to treat and provide any healthcare services to my child that the provider deem necessary for treatment and/or diagnosis including biopsies. I also understand in Unaccompanied Minors I grant permission to treat and provide any healthcare services to my child that the provider deems necessary for treatment if my child arrives at the office unaccompanied* Initials I further acknowledge this consent will remain in effect until either I revoke in writing and delivered to you or the minor reaches the age of 18 years. Patient Name Date of Birth Parent/Legal Guardian Signature Date Witness Signature Date Name SSN Date of Birth Relationship Work Cell Home Other Individuals Allowed to Accompany My Child. Without a signed consent form we cannot legally treat a minor child. the course of treatment photographs may be taken for clinical or educational purposes. If you are not the parent but are the legal guardian you will need to provide legal documentation that you are the legal guardian* This information will be kept in the child s file. If you are not the parent but are the legal guardian you will need to provide legal documentation that you are the legal guardian* This information will be kept in the child s file. Minor Accompanied by others If I am unable to accompany my child to the appointment the below listed individuals have my permission accompany my child. Minor Accompanied by others If I am unable to accompany my child to the appointment the below listed individuals have my permission accompany my child. This agreement is required in order for the unaccompanied child to be seen and treated* Initials CONSENT TO TREAT MINOR I authorize Tyler Oral Facial Surgery to treat and provide any healthcare services to my child that the provider deem necessary for treatment and/or diagnosis including biopsies. This agreement is required in order for the unaccompanied child to be seen and treated* Initials CONSENT TO TREAT MINOR I authorize Tyler Oral Facial Surgery to treat and provide any healthcare services to my child that the provider deem necessary for treatment and/or diagnosis including biopsies. I also understand in Unaccompanied Minors I grant permission to treat and provide any healthcare services to my child that the provider deems necessary for treatment if my child arrives at the office unaccompanied* Initials I further acknowledge this consent will remain in effect until either I revoke in writing and delivered to you or the minor reaches the age of 18 years..