Secretary's Stationary - Florida Department of...

Mission:To protect, promote & improve the healthof all people in Florida through integratedstate, county & community efforts.

Rick ScottGovernor

Celeste Philip, MD, MPHInterim State Surgeon General

Vision: To be the Healthiest State in the Nation

Non-Parent/GuardianAuthorization for Consent to Medical Care and Treatment

I, the undersigned, as parent or legal guardian for:

Child’s Name ______________________________________ Date of Birth ________________

Child’s Name ______________________________________ Date of Birth ________________

do hereby authorize and grant the below named individual(s) the authority to give informed dental consent for any and all dental procedures or treatments deemed necessary for the well-being of my minor child(ren) named above.Name __________________________________________ Phone ________________________

Address ______________________________________________________________________

Relationship to Child(ren) _______________________________

Name __________________________________________ Phone ________________________

Address ______________________________________________________________________

Relationship to Child(ren) _______________________________

This authorization is for:□ Today’s date only.□ A specific date of:_________________________________.□ All future visits effective for one (1) year from today’s date.

I realize that it is my duty to update and notify the Health Department of any necessary changes that must be made to this document within a timely manner. I also understand that to ensure this document is accurate I will be required to complete it annually.

Parent/Guardian ___________________________________________Signed this ________ day of _________________________, 20_____

Witness __________________________________________________STATE OF FLORIDA/ _______________ COUNTYBefore me, the undersigned authority, appeared the above parent guardian, who being duly identified signed this instrument in my presence this _______ day of _______________________, 20_____.

Notary Public ___________________________ My commission expires: ___________________

Florida Department of Healthin Leon County • Molar Express912 Railroad Avenue Tallahassee, FL 32310PHONE: 850-606-8400 • FAX: 850-921-9770FloridaHealth.gov