South Bend

Forms for Legal Guardians

Note to Parents & Legal Guardians:

If you, as parent or legal guardian, need to authorize someone to bring your child to an appointment or make any decisions regarding care, please fill out this form below. Notice, you must be parent or legal guardian to fill out this form.

(Spanish) Si usted, como padre o tutor legal, necesita autorizar a alguien mas a llevar a su hijo/a a una cita o tomar cualquier decisión con respecto a la atención dental, completa este forma que sigue. Aviso, debe ser padre o tutor legal para completar este forma.

Update Patient Information

If you are an existing patient of our practice and you have been instructed to update patient information, please click on the link below: