Heartland Dental Care
Buttermilk Family and Cosmetic Dentistry / 618 Buttermilk Pike, Crescent Springs, KY, 41017 / 859-344-9222

I ____________________, authorize my child/minor ____________________, to have dental treatment without my physical presence in the dental office. I have been advised that it is ideal to have a parent/legal guardian present during treatment in case of any complications or medical situations that may arise. With knowledge of this, I authorize Dr. Gregory Pohl and the Buttermilk Family and Cosmetic Dentistry team to take any emergency action deemed necessary. I still retain the authority to approve or decline treatment to be rendered and will make the designation clear before the appointment either  in person or by telephone consent. 

Patient Name:                       
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Signature of Parent/Guardian: 
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Signature of Doctor:
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Date:
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