• Date Format: MM slash DD slash YYYY
  • I. GENERAL CONSENT

    This section is a general consent used for all dental treatment at ABC123 Pediatric Dentistry.

    DRUGS AND MEDICATION

    I understand that antibiotics, analgesics, and other medications can cause allergic reactions such as redness or a rash, swelling of tissue, pain itching, vomiting, and/or anaphylactic shock (severe allergic reaction requiring hospitalization). I have informed the dentist of any allergies that my child has and complete medical history has been given.

    TREATMENT

    I understand that my insurance may provide only the minimum standards of care. I elect to follow Dr. Diaz’s recommendation of optimal treatment as detailed in treatment plan. I understand that the information presented to me on the treatment plan is an estimate, and there may be some adjustments in the fees based on what the insurance pays.

    CHANGES IN TREATMENT

    I understand that during the treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination.

    PARENT/LEGALGUARDIAN

    I understand that no parent/legal guardian is allowed in treatment room if my child is undergoing dental treatment, unless specifically requested by the dentist. We request that you do not leave the office for any reason as a precaution in the event of an emergency. No photography nor videography is allowed at any time during procedures. We will inform you of any changes in treatment.

    II. PROCEDURAL CONSENT

    This section is a procedural consent. Although there are multiple procedures listed below, please review the specific procedures on your child’s treatment plan previously discussed with you.

    A. SOFT TISSUE SURGERY- I understand that my child will be having laser soft tissue surgery. Some of the possible complications include bleeding, swelling, and pain.

    B. FILLINGS/RESTORATIONS- I understand that my child will be having filling(s) today and that all fillings will be in a tooth colored shade. I understand that this office does NOT do any amalgam (silver) restorations.

    C. PULPOTOMY- A pulpotomy is the partial removal of the pulp tissue or nerve. Medication is placed in the remaining pulp tissue and the tooth is closed. I understand that there is no guarantee that this treatment will save my child’s tooth, and in the case of severe infection on the tooth may abscess and need extraction.

    D. SEALANT- Is a thin, plastic coating painted on the chewing surface, usually on back teeth to prevent tooth decay. It quickly bonds into the grooves of the teeth forming a protective shield over the enamel of each tooth

    E. PREVENTIVE RESIN RESTORATION- Is a thin, resin coating applied to the chewing surface of molars, premolars and deep grooves of teeth. Repairs small decay and protects the tooth from further decay.

    F. CROWNS- I understand that four options are available for teeth requiring crowns. They are as follows:

       a. Stainless Steel Crowns (SSCs) are the more durable of the two options and can withstand maximal forces for chewing. They require minimal reduction of your child’s tooth, but are the least esthetic.

       b. Nu Smile Crowns (NSCs) have resin on the front or chewing surface of the crown and stainless steel on the back/sides of the crown. NSCs are durable because of the underlying stainless steel and esthetic due to the resin. The few negatives to this type of crowns are as follows: only one color is available, requires more reduction of the tooth, cost, and on occasion, the resin may fracture off the crown.

       c. Resin Based Crown- Your child is having a resin crown which is a tooth is colored filling material wrapped completely around their tooth. The advantage of this restoration is the esthetics and the disadvantage is that it is fragile. Your child will need to be careful when biting into anything hard.

       d. EZ Pedo Crowns (Zirconia/Porcelain) are made from certified biocompatible, medical grade Zirconia. These crowns are the most esthetic option for primary teeth. The negative is that they can fracture. If this crown comes loose it will require an entirely new crown. EZ Pedo crowns CANNOT be recemented.

    G. EXTRACTION/REMOVAL OF TEETH-

       a. I understand that if my child’s tooth is abscessed the only recommended treatment alternative is an extraction. I understand that removing teeth may not always eliminate the infection and further treatment may be needed. I understand that not extracting abscessed teeth may lead to severe infection requiring hospitalizations.

       b. I understand the risk of having teeth extracted are as follows: bleeding soreness from holding the mouth open, pain, swelling, spread of infection, dry socket, exposed sinuses, loss of feeling on other teeth, lips, tongue, and surrounding tissue that can last for an unlimited time. I understand that other teeth in close proximity may be inadvertently loosened or extracted.

    H. APPLIANCES- I understand that appliances are artificial, constructed in metal, and/or porcelain.

       a. I understand that any appliance requiring an impression must be seated in a timely manner or the appliance may not fit. I understand it is my responsibility to bring my child for the delivery of appliance. I understand that failure to make and/or keep delivery appointment may result in poorly fitting appliances. If a remake is required due to my delay of more than 30 days there will be additional charges.

       b. I understand that it is my responsibility to monitor the hygiene and dietary habits of my child in order to prolong the life of the appliance and prevent decay underneath the bands of the appliance. I understand that my child needs to refrain from eating any substance that may cause the appliance to become loose (e.g. gum, sticky candy or substances, etc.)

    III. BEHAVIOR MANGEMENT

    I understand there are various techniques available for behavior management and each one has an associated fee as per the treatment plan. The techniques are as follow:

    A) NITROUS OXIDE- I elect for my child to receive nitrous in conjunction with their dental treatment. I understand that some of the possible side effects include: nausea, vomiting, dizziness, and headaches. I understand that nitrous is not indicated for pregnant females.

    B) ACTIVE PROTECTIVE STABILIZATION- is the physical limitation of a patient’s movement by a person, restrictive equipment, materials or devices for a finite period of time. Two types of protective stabilizations are:

    Passive: Which utilizes a restraining devices such as a papoose board. This will NOT be used today.

    Active: Which involves the physical limitation of movement by another person, such as the parent or guardian, dentist, or dental assistant.

    IV. ACKNOWLEDGMENT & SIGNATURE

    I acknowledge no guarantee or assurance has been made by anyone regarding dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to proposed treatment.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.