Policy for Treatment of Minors

A parent or legal guardian accompanying the minor is responsible for the payment of the patient’s
account regardless of who holds the insurance policy. Unaccompanied minors can be denied nonemergency
treatment until a parent or legal guardian is present or until such time as we receive written
permission for the treatment and payment of the account.

We require that all minors be accompanied by a parent or legal guardian for the initial visit, we will see
minors without a parent or guardian if the parent or guardian has provided written permission.

Authorization To Provide Dental Care For Minor

I am the custodial parent having legal custody of

a minor (under age 18) child, date of birth

I authorize my child to consent to care and/or treatment at Aaron Tropmann,
DDS.PA. & Gary D. Oyster, DDS. without my presence. By signing here, I indicate that I have the
understanding and capacity to communicate health care decisions and that I am fully informed as to the
contents of this document and understand the full importance of this grant. I understand and agree that I
am liable for any and all charges incurred by the treatment of the above patient.

Limitations on such consent and treatment are as follows (if none write none on the line below).

This consent has the following time limitation (if none write none on the line below).

Custodial Parent Contact Information

Custodial Parent Name

Work Phone Number

Home Phone Number

Mobile Phone Number

Custodial Parent Signature

Date

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