Additional Consent Form
Dental Treatment Consent Form

I understand that both the dentists and dental assistants may treat my child for the following dental
procedures, which may be necessary to provide dental treatment. I not only understand that I will be given
an explanation why treatments will be performed, but also understand that the normal provided procedures
for a first time patient may include a comprehensive or limited exam, dental cleaning, fluoride applications,
sealants, and radiographs (x-rays) as necessary. However, this is subject to change depending on numerous
factors, including, the patient’s behavior, the amount of future work, and time.

In general terms, the procedures that you or your child may need include:
A. Applications of sealants
B. Root canals (permanent teeth) or pulpotomies (primary teeth)
C. Porcelain crowns or stainless steel crowns
D. Restoration of broken teeth or fillings
E. Treatment of infected teeth or gums
F. Extractions of 1 or more teeth
G. Use of supports to safely perform necessary dental procedures
H. Use of nitrous oxide to help reduce anxiety as needed
I. Use of local anesthetics, oral anesthesia or oral sedatives as needed

Patient Name: *
Your answer
Patient Date of Birth: *
MM
/
DD
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YYYY
Parent / Guardian's eSignature: *
Both the treatment and suggested alternative methods of treatment, as well as the advantages and disadvantages of each, will be fully explained to me. I have been advised that, although the best results are expected, there is no way within reason, of anticipating complications. Therefore, it is not possible to guarantee the results of the treatment. However, the occurrence is remote I recognize that some risks are associated with dental procedures; I understand and accept that certain complications may be serious or require medical intervention.
Your answer
Date:
MM
/
DD
/
YYYY
I give permission to the following adults to bring my child to appointments and also make treatment change decisions.
1. Name of Adult: *
First and Last Name:
Your answer
1. Relationship to Patient: *
Your answer
2. Name of Adult:
First and Last Name:
Your answer
2. Relationship to Patient
Your answer
3. Name of Adult:
First and Last Name
Your answer
3. Relationship to Patient
Your answer
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