AUTHORIZATION TO CONSENT TO DENTAL TREATMENT FOR A MINOR CHILD
, A MINOR CHILD, HEREBY AUTHORIZES
WHO IS 18 YEARS OF AGE OR OLDER, TO OBTAIN AND CONSENT TO ANY AND ALL DENTAL CARE AND TREATMENT REQUIRED BY SUCH MINOR CHILD IN THE ABSENCE OF THE UNDERSIGNED. MY CONSENT SHALL REMAIN EFFECTIVE UNTIL THIS INSTRUMENT IS REVOKED BY ME IN WRITING.

THE COMPLETION OF THIS FORM SUPERSEDES ALL PREVIOUS AUTHORIZATION TO CONSENT DENTAL TREATMENT FOR A MINOR CHILD FORMS (EXCEPT IN CIRCUMSTANCES OF JOINT CUSTODY FORMS).