secretary's stationary - florida department of...
Post on 17-Jun-2020
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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
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