Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

PATIENT INFORMATION AND CONSENT FORM FOR ENDODONTIC SURGERY

Date:
Patient:
Date of Birth:
Phone:
Email

Person(s) I authorize to accompany my child:

Name:
Relationship to child:
Name:
Relationship to child:
Name:
Relationship to child:

This is an authorization for the office of, Iván E. Rodríguez, D.M.D., Adalí Efraín Vélez, D.M.D., Ernesto G. Treviño, D.D.S., and their assistants as they may designate, to render dental care to my child. I consent to any dental care which encompasses diagnostic or dental treatment which my dentist or their designee may deem necessary for my child's dental health and well-being.

This authorization will remain effective unless terminated by written notice. Phone number where parent can be contacted during treatment, if needed:

Cell phone number:
Work phone number:

Parent/ Guardian Signature

Use your mouse cursor or the tip of your finger to sign below

Date:
Relationship to Patient :

Witness Signature

Use your mouse cursor or the tip of your finger to sign below

Date: