Alternate Representation Form

*Parent consenting to alternate adult representation must be one of the parents listed on original paperwork for the patient. If you have a question about who is listed on your child’s original paperwork, please call our office for details.

Date of Appointment

Patient Name

Parent Name

Parent Email Address on File at Smile Wonders

Alternate Responsible Party Name

Acknowledgment and ApprovalI, the parent of [the patient listed above], request Smile Wonders, PLLC to accept consent to treat by [Alternative Responsible Party (ARP) listed above] in my absence. They may consent to treatment for treatment recommeded by the team and doctors of Smile Wonders PLLC including but not limited to professional cleaning, fluoride treatment, any necessary x-rays, restorative treatment (fillings, nerve treatments, tooth colored or stainless steel crowns/caps, extractions, sealants, soft tissue surgery (frenectomy, frenuloplasty, drainage of an infected tooth, gingival recontouring), trauma treatment, as applicable.
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I understand that the ARP accompanying my child to Smile Wonders will be required to submit payment for services rendered (or a portion thereof if in-network or PPO insurance plan is on file). I understand that I may choose to keep a credit card number on file for this circumstance and it will be charged on dates of service where I am not present when the above named person is attending dental appointments with my child(ren). If I do not have a credit card on file, I understand that the above named person will be responsible for any payment necessary at Smile Wonders.
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I understand that I am able to remotely participate during the appointment as long as the ARP is able to reach me via phone or video call while the appointment is in progress. If I cannot be reached during the scheduled appointment, and I am interested in discussing any findings, recommended treatment or any oral hygiene instructions, I understand that I can request to schedule a teledentistry office visit appointment with the doctor.
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On the same note, if I cannot be reached during the scheduled appointment, and there are any significant/concerning pathological findings or treatment recommendations, the pediatric dentists at Smile Wonders may request that a separate teledentistry office visit appointment is scheduled at a time convenient to me and the doctors so that discussion and planning for the treatment needed.

I understand that in most cases a separate appointment may not be necessary as parents can be reached during the scheduled appointment. However, if for either of the reasons listed above, a teledentistry office visit is required, there will be additional fees applicable.

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