Unaccompanied Minors Form

ORTHODONTIC APPOINTMENT PERMISSION
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
We know your schedule is busy and it’s not always convenient to accompany your child to every appointment. Whether your child is brought in by Grandma, another family member or a friend, or is old enough to drive themselves, we want to make getting to their orthodontic appointments as easy as possible for your family. By signing below, you're giving Johnson Orthodontics permission to see your child for their regularly scheduled orthodontic appointments, even when you aren't here.
What does this mean?
- We can complete routine orthodontic adjustments and other visits that are already part of your child's treatment plan.
- We'll keep you in the loop! Appointment summaries, instructions and recommendations will be shared with you by text or email.
- You're still in charge of the big decisions. This permission does not authorize changes to your child's treatment plan or other major treatment decisions.
Please check one:
Parent/Legal Guardian Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
This permission remains in effect until I withdraw it in writing, my child turns 18, or active orthodontic treatment is completed, whichever comes first.
Should be Empty:

ORTHODONTIC APPOINTMENT PERMISSION