PAEDIATRIC DENTISTRY CONSENT FOR DENTAL PROCEDURES

It is the policy of this dental practice to inform parents of all procedures contemplated for your child. At each examination
appointment, we will identify any dental treatment needed and describe this to you and your child.
 Each regular examination visit consists of oral hygiene instructions, cleaning of the teeth, topical application of fluoride,
radiographs (X-rays) if needed and examination of the teeth, hard and soft tissues of the mouth and the bite.
 Any other treatment needed such as fillings, caps, extractions, etc. will be performed at a separate appointment after obtaining
your permission.
Indian Law requires that we obtain your written informed consent for any treatment given to your child as a legal minor.
1. I hereby authorize and direct Dr.____________________ assisted by other dentists and/or dental auxiliaries of his/her choice,
to perform the following dental treatment or oral surgery procedures, including the use of any necessary or advisable local
anaesthesia, radiographs (X-rays) or diagnostic aids.
2. In general terms the dental procedures or operation will include:
o Cleaning of the teeth and the application of topical fluoride.
o Application of plastic “sealants” to the grooves of the teeth.
o Treatment of the diseased or injured teeth with dental restoration (filling or caps).
o Replacement of missing teeth with dental prosthesis.
o Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.
3. Use of local anesthesia, by injection, to numb the teeth worked on. Numbness usually lasts from 1 ½ to 3 hours. Allergic
reactions are rare. Your child will be cautioned not to bite the numb lip and check. Please do not tell your child that they are
going to get a “shot” as we have our special way of informing them about this.
4. Nitrous Oxide (laughing gas) is used to relax children so that they feel less pain of the injection.This gas is placed over the
child’s nose. Again, this gas is very safe. The nose piece, as with all treatment, will not be forced onthe child.
I fully understand there is a possibility of surgical and/or medical complications developing during or after the procedure.
I further authorize Dr. _______________to perform treatment to preserve the dental health of my child.
I further understand that parents must remain in the reception area for the duration of their child’s visit. However, for the initial
visit, that parent will accompany the child to the consultation area. Upon completion of consultation, the parent will be requested to
return to the reception area.
I hereby state that I have read and understand this consent form and that all questions about the procedures have been answered in
a satisfactory manner. I understand that I have a right to be provided with answers to questions which may arise during the course
of my child’s treatment.
I further understand that this consent will remain in effect until such time that I choose to terminate it.
Date: ____________________________________
Time: ___________________________________________ AM / PM
Patient’s Name: __________________________________________________
Signature of Parent/Guardian: _____________________________________
Relationship to Patient: ________________________

Behaviour Management Techniques

Among the behaviours that can interfere with the proper provision of quality dental care are: Hyperactivity, resistive movements,
refusing to open the mouth or keep it open long enough to perform the necessary dental treatment and even aggressive or physical
resistance to treatment, such as kicking, screaming and grabbing the dentist’s hands or the sharp dental instruments.
All efforts will be made to obtain the cooperation of the child dental patients by the use of warmth, friendliness, persuasion,
humour, charm, gentleness, kindness and understanding. There are several behaviour management techniques that are used by
paediatric dentists to gain the cooperation of child - patients to eliminate disruptive behaviour or prevent them from causing injury
to themselves due to uncontrollable movements. The more frequently used paediatric dentistry behaviour management techniques
are as follows:
Tell-show-do: The dentist or assistant explains to the child what is to be done using simple terminology and repetition and then
shows the child what is to be done by demonstrating with instruments on a model or the child’s or dentist’s finger. Then the
procedure is performed in the child’s mouth as described. Praise is used to reinforce cooperative behaviour.
 Positive reinforcement: This technique rewards the child who displays any behaviour which is desirable. Rewards include
compliments.
 Voice control: The attention of a disruptive child is gained by changing the tone or increasing the volume of the dentist’s voice.
Content of the conversation is less important than the abrupt or sudden nature of a command.
 Mouth props: A rubber or plastic device is placed in the child’s mouth to prevent closing when a child refuses or has difficulty
maintaining an open mouth.
 Sedations: Sometimes drugs are used to relax a child who does not respond to other behaviour management techniques or who
is unable to comprehend or cooperate for the dental procedures. These drugs may be administered orally, by injection or as a
gas (nitrous oxide and oxygen).Your child will not be sedated without you being informed and obtaining your specific consent
for such procedure.
 General anaesthesia: The dentist performs the dental treatment with the child anesthetized in the hospital operating room. Your
child will not be given general anaesthesia without you being informed and obtaining your specific consent for such procedure.

Initials: ________________________________ Date: _________________________________

 ददद दददददददददद ददददददददददद दद ददद ददद-ददद दददददददद ददददद

दद दददद ददद दददददददद ददददददद दद दददद दद, दद दददद ददददद दद ददददददद ददद ददददददददददद दद, दद दददद
दददद दद ददददद दददद द दददददददद दददद दददददददद दद, दद ददद दददद दद ददद दददददददद ददददद दद ददददद
दददद ददद दद दददद दद दददद ददददद दद दददद ददददद ददददददद
• दददददददद दददददद दददद दददददददद ददद ददददद दददददददद ददददददद, दददददद दद दददद, दददददददद दद
ददददददद ददददददददद, ददददददददददद (दददद-दददद) दद दददददददद दददद दद दद दददददद दद दददद, दददद दद
दददद दद दददददद ददद दददद दददद
• दददद दददददद ददददददद दददद दद ददद दद ददद दददददददद दद दददद, ददददद, ददददददददद ददददददद दददद दददद
दद दददद ददददद दद दददददददद ददददद
दददददद ददददद दद ददद दददददद दद दद दद दददद ददददद दद दददददद ददददददद दद ददद ददद ददद दद दददद दद
दददद दद ददद दददद ददददद ददददद ददददद ददददददद ददददद
1. ददद दद दददददद दददद ददद दददददददद ददददद दद ददददद दददददद ददददददददददद दद दददद दद ददद दददद दद
दददददद दद ददददददद ददददददद ददददददददद, ददददददददददद (दददद-दद) दद ददददददद दददददद दद ददददद दददद
दददद ददद दददददददददद दद / दद ददद ददददद ददददददद दददददद दददददद ददददददद दद .____________________ दद
दददददद दद ददददददददद दददद ददद द
2. ददददददद दददददद ददद ददद ददददददददददद दद दददददद ददद ददददद ददददद:
द दददददद दद दददद दद दददददद दददददददद दद दददददद
o दददददद दद ददददद दद ददद ददददददददद "दददददददद" दद दददददद
o दददददद दद ददददद (दददद दद ददददद) दद ददद ददददददददद दद दददद दददददद दद दददददद
द ददद ददददददद ददददद दद ददद ददददद दददददद दद दददददददददददद
द दददददददददददददद (ददददद) दददददद दद / दद ददददद ददददद दद ददददद दददददददददददद दद दददददद
3. दददददददद दददददद, ददददददद दददददद दद ददददद, दददददद दद दद दददद दद ददद दददद दददद ददद ददददद
दददद ददददद दद 1½ दद 3 दददद दद दददद ददद दददददद ददददददददददददद दददददद दददद दददद ददददद दद ददददददद
दद ददददद दद दददददद दददद दद ददददद दद दददद द ददददद ददददद दददद ददददद दद दद द ददददद दद दददददद
"ददद" ददददददद दददद दद ददद ददद ददददददद ददददद ददद दददद दददद ददद ददददद दददद दद ददददद ददददद ददददद
ददद
4. दददददद दद दददद दददद दद ददद ददददददद ददददददद (दददद ददद) दद ददददद दददद दददद दद दददद दददददद
दददददददद दद दद दददद ददददद ददद दद ददद ददददद दद ददद दद ददद दददद ददद ददद, दद ददद दददद दददददददद
ददद ददद दददददद, दददद दद ददद ददददद दद ददद, ददददद दद ददददद दददद दददद दददददद
ददद दददद ददद दद ददददद ददद दद ददददददददद दद ददददद दद दददद ददद दददददददद दददद दददददददद दद / दद
दददददददद दददददददद दद ददददददद ददद
ददद दददद ददददद दद ददद ददददददददद दद दददददददद दददद दद ददद ददददद दददद दद ददद दद _______________ दद
ददद दददददद दददद दददद
ददद ददद ददददद ददद दद दददद-दददद दद दददद ददददद दद दददददद दद दददद दद ददद दददददददद ददददददद ददद
दददद दददददद ददददददद, ददददददददद दददददद दद ददद, दद दददद-दददद ददददद दद ददद ददददददद ददददददद ददद
दददददद ददददददद दददद दददद दद, दददद-दददद दद दददददददद ददददददद ददद ददददद दद दददददद दददद दददददद
ददद दद दददददद ददददद ददद दद ददददद दद ददददद दददद दद ददद दद ददद दददद दद दद ददददददददददद दद दददद
ददद ददद दददददददद दद ददददद दददददददद ददददद दद दददद ददद ददद ददद ददददद ददद दद दददद दददद दददददद
दद दददद दद ददददद ददददददद दददद दददद दददददददद दद ददददद दददददद दददद दद दददददद ददद
ददद ददद ददददद ददद दद दद ददददद दद दद ददददददद ददददद दद दद दद ददद ददद दददददद दददद दददद दददददद
ददददद: ____________________________________
ददद: ___________________________________________ ददददददददद / ददददददद
दददद दद ददद: __________________________________________________
ददददददद / ददददददद दद ददददददददद: _____________________________________
दददद दद ददद ददददद: ________________________

ववववववव ववववववव ववववववव

दददददददद दददद ददद दददददददद दददददद दद दददद दददददददद ददद ददददददददद दददद दददद ददददददददद ददद दद
ददद: ददद दददददददद, ददददददददद दददददद, दददद ददददद दद ददददद दद ददद दद दद ददद दददददद दददद ददददद
दददद दद ददद दददददददद दददद ददद दद दददद दददद दद दद दददद दद दद ददददददद दद ददददद दद ददद ददददददद
दददददददद, दददद ददद ददददद , ददद दददददददद दद ददददद दद ददद ददद दददददददद ददददददद दद दददददददद दद
ददददददद
ददददद, ददददददद, दददददद, ददददद, दददददद, दददददद, ददददददद दद ददद दद ददददद दद ददद ददद ददददददद दद
ददददद दद ददददददद दददद दद ददद ददद दददददद ददद ददददददद दद ददददददद ददददददद ददददददद ददद ददददद
ददददद ददद दददददददद ददद दददददददददद दददददद दददददद दद ददददद दद ददददददद दददद दद ददद दददद दददद दद
- ददददददद दद ददददददददद ददददददद दद दददद दददद दद दददददददददद दददददददद दद दददद ददद दद ददद
दददददददद दद ददददद दद दददद ददददददददद ददददद ददद दददद दददद ददद दददददददद ददद दददददददद ददददददद
ददददददद ददददददद ददददददददददद ददद:
ददद-दद-दद: ददद दददददददद दद ददददद ददददद दद ददददद दद दद ददद दददददददद दद ददददददददददद दद ददददद
दददद दददद दददद दददद ददददद दद ददद ददददद दद दददददद दद दद दददद दद ददददद दद ददद दददददददद दद ददददद
दद ददददददद दद ददद दददददददद दददद दददद दददद दददद ददद ददद ददददद दद दददददद ददददद दद दददद ददद
ददददददददद दद दददद ददद दददददद ददददददद दद ददददद दददद दद ददद ददददददद दद ददददद दददद दददद ददद
• ददददददददद ददददददददद: दद ददददद दद ददददद दद दददददददद दददद दद दद दददददद दददद दद ददददददद दद
ददददददददद दददद ददद दददददददददद ददद ददददददद ददददद ददद
• दददद दददददददद: दद ददददददददद ददददद दद ददददद दददद दद ददददद दद ददद दददददददद दद ददददद दद दददददद
ददद दददददद दददद ददददददद दददद दददद ददद ददददददददद दद ददददददद ददददद दद ददददद दद ददददद ददददददद
दद दद दददददददददद ददद
• दददद ददददद: ददददद दद दददद ददद दद ददद दद ददददददददद दददददद ददद दददद दद दददद ददददद दद ददद दद
दददद दद ददद दद दददद दददद दद दददद दददद ददद दददददद ददद
• दददददद: ददद-ददद ददद ददददद दद दददद दददद दद ददद ददददद दद ददददद दददद दददद दद दद दददद ददददददद
ददददददद ददददददद दद दददद दददद दददद ददद दद दद ददद ददददददददददद दद ददद ददददद दद ददददद दददद ददद
दददददद दददद दद ददददद दद दददददददद दद ददद (ददददददद ददददददद दद ददददददद) दद ददद ददद ददददद ददद दद
दददददददद दददद दद दददद ददद दददद ददददद दद दददद ददददद ददद दददद दद दद ददद दद ददददददददद दद ददद
दददद ददददददद ददददद ददददददद ददद दददद ददददद दददद दददद दददददद
• ददददददद ददददददददद: ददद दददददददद ददददददद ददददददद दददद ददद दददददददददद ददददद दद ददद ददद
दददददददद ददददद दददद ददद दददद ददददद ददद दददद दददद ददददद दद ददददददद ददददददददद दददद दददद ददददद
दद ददद ददददददददद दद ददद दददद ददददददद ददददद ददददददद दददद ददददद

ददददददददद: ________________________________ दददददद:

_________________________________