Authorization for Agent to Consent to Dental Treatment of a Minor


(an adult into whose care the minor has been entrusted) to consent to any X-ray examination, anesthetic, or dental diagnosis or treatment for that is deemed advisable by Dr.
Abhijit Gune, provided by Dr. Gune or under Dr. Gune's supervision regardless of where that treatment is provided.

This authorization is made under California Family Code §6910.

Please specify relationship to minor: