CONSENT FORM PEDIATRIC DENTAL TREATMENT

As a parent it is your right to understand the risks, benefits, and alternate dental
treatment options for your child. You may accept or refuse treatment offered to your
child. Please read this form carefully and ask about anything you do not understand.

Every child is a unique individual thus not every child will require the same dental
treatment. Based upon your child’s

age, teeth present, and tooth position, the doctor will determine what treatment is
necessary. Your child’s exam appointment may include a comprehensive exam, fluoride
treatment, teeth cleaning, and radiographs (x-rays) if necessary. If you have any questions
or concerns about our examination procedures, please feel free to discuss this with the
doctor or her staff prior to your child’s dental visit.

CONSENT FORM PEDIATRIC DENTAL TREATMENT

As a parent it is your right to understand the risks, benefits, and alternate dental treatment
options for your child. You may accept or refuse treatment offered to your child. Please
read this form carefully and ask about anything you do not understand.

Treatment alternatives, including no treatment, have been presented to me and all of my

questions regarding my child’s

care have been answered satisfactorily.

I understand that treatment for children includes efforts to guide their behavior by helping
them to understand the treatment in terms appropriate for their age. Behavior will be
guided using praise, explanation and demonstration of procedures and instruments, using
variable voice tone and

loudness.
I further request and authorize the taking of oral dental

x-rays and the use of such anaesthetics as may be consider ed necessary to treat the
patient’s dental problem.
When employing oral sedation or in emergency situations in paediatric dentistry, it
becomes necessary to control excessive head, arm and leg movement in order to provide
safe, comfortable and quality dental treatment. Almost always, these patients are very
young, extremely fearful and/or moderately to severely disabled.

PHOTO CONSENT

For the purpose of advancing medical-dental education, I give permission for the use of
clinical photographs of the patient for diagnostic, scientific, educational, or research
purposes.

Patient name:

Parent signature:

Doctor signature & stamp:

Witness signature: