CAREGIVER AUTHORIZATION/CONSENT

Please complete and submit the form below if your child will be brought to tooth & co by someone OTHER than a parent/legal guardian. Use a separate form for each child.

Child/Children's Name(s)

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Phone

(###)

###

####

Caregiver's Name

Nanny, Grandparent, Aunt, etc.

First Name

Last Name

Caregiver Phone

Phone to contact the person that will be coming to the appointment.

(###)

###

####

Relationship to Patient

I authorize the above named caregiver to make any dental and medical decisions, including consent to any changes in the treatment plan as they may arise at the time of the treatment, during my child's dental appointment. I agree to pay for my portion of the services provided to my child same day as the treatment is rendered.

Electronic Signature

tooth&co Pediatric Dentistry

Nurturing Young Smiles

Tooth & Co. Pediatric Dentistry (Tooth and Company) is the new pediatric dental specialist practice of Dr Ellie Sakhi, DDS, MS. Appointments: 952-920-8234. Dr Sakhi has been "Nurturing Young Smiles" in Minnesota for the last 15 years and recently opened her private practice in a brand new office located at 4330 Highway 7 (County Rd 25), in St Louis Park. The location is conveniently one mile West of Lake Calhoun and one mile East of Hwy 100. Dr Sakhi completed her pediatric dental specialist training at the University of Minnesota.

Tooth & Co | 4330 Highway 7, St Louis Park, MN, 55416, United States