Nhat Khanh Dentistry

Consent for Treatment of a Minor

For patients under 18. The parent or legal guardian completes this form to authorize dental care for the minor patient.

5296 University Ave, Suite I

San Diego, CA 92105

(619) 265-2262

Fields marked * are required.

Minor (Patient) Information

Minor's Full Legal Name*

Minor's Date of Birth*

MM/DD/YYYY

Age Group*

Under 13
13 – 15
16 – 17

Guardianship Status

I am the minor's…*

Biological or adoptive parent (with legal authority to consent — see help text)
Court-appointed legal guardian (documentation required at first visit)
Foster parent (with authority to consent to medical/dental care)
Step-parent with written authorization from parent
Grandparent or other relative caregiver (CACG affidavit required)
The minor themselves — they are legally emancipated (see Step 3)
The minor themselves — minor is 15+, living separately, managing own affairs (Family Code § 6922)

Guardian Full Legal Name*

Guardian Date of Birth*

MM/DD/YYYY

Guardian Phone*

Guardian Email

Guardian Mailing Address

If I am consenting as a foster parent or other state-authorized caregiver, I understand I must provide a copy of the court order, county placement documentation, or other authority that authorizes me to consent to the minor's dental care. Under California Welfare & Institutions Code § 369, certain dependent minors' care decisions require additional notice or court authorization.

I have completed (or will complete before the minor's first visit) a California Caregiver's Authorization Affidavit under Family Code § 6550, which grants me authority to consent to the minor's school-related medical care including dental care. I will provide a copy to the practice.

Under California Family Code § 6922, I attest that I am 15 years of age or older, I am living separately from my parents or legal guardian (with or without consent), and I am managing my own financial affairs. I understand the practice may require additional information to verify these conditions.

Emancipated Minor (if applicable)

Under California Family Code § 7002, a minor may consent to their own care if they are married, in active military service, or have received a court declaration of emancipation. If this applies, please complete this section.

Basis for emancipation*

Married (or formerly married)
Active duty military service
Court declaration of emancipation (Family Code § 7122)

I understand I must provide documentation of my emancipation status (marriage certificate, military ID, or court order) at my first visit. The practice may decline to provide non-emergency treatment until documentation is confirmed.

Authorization for Care

I authorize the dental team at this practice to provide dental examinations, cleanings, radiographs (x-rays), preventive care, and routine restorative dental treatment for the minor named above. This authorization remains in effect until I revoke it in writing, the minor turns 18, or 12 months from signing — whichever comes first. The practice will ask me to re-confirm this authorization at least annually.

I understand that this general authorization covers routine examinations, cleanings, radiographs (x-rays), preventive care, and routine restorative treatment. Any procedure with material risk (including but not limited to extractions, root canals, crowns, sedation beyond local anesthetic, and any surgical procedure) will require a separate procedure-specific informed consent at the time of treatment planning, which I will be asked to review and sign.

In the event of a true dental emergency (uncontrolled bleeding, severe infection with risk of spread, severe trauma, or severe acute pain that cannot wait) where I cannot be reached after reasonable attempts to contact me, I authorize the dental team to provide only that treatment necessary to stabilize the minor's condition and relieve immediate pain or infection. Non-emergency or elective treatment will not be provided until I am reached and have given specific consent. I will provide an alternate emergency contact below.

Emergency contact name (if guardian cannot be reached)*

Emergency contact phone*

Emergency contact relationship to minor*

Parental presence preference*

A parent / guardian will be present at every visit
Present at the first visit and major treatment-planning visits only
An authorized adult (listed below) may bring the minor to routine visits

Authorized adults who may bring the minor to visits (optional)

Financial Responsibility

I accept financial responsibility for dental services provided to the minor named above. I understand insurance estimates are not guarantees of payment, and I am responsible for any balance not paid by insurance.

Primary insurance policyholder name (if different from guardian)

Signature

Signer Name (printed)*

Signature*

Signature

Date Signed*

MM/DD/YYYY

Witness / Staff Member Name (printed)

Optional — leave blank if no staff member is present (e.g., filling at home). Staff can add their name later in the office.

Witness / Staff Signature

Signature