Happy Dental Treatment Consent printable pdf download

DENTAL TREATMENT CONSENT

Date __________________

Patient’s name ___________________________ Pt. # __________

DOB _____________

As health professionals, we must obtain your consent for the dental/oral treatment of your child.

Please read this form carefully and feel free to ask any questions that may not be clear to you.

1. I, ____________________________________, as the parent or guardian of the patient

identiﬁed above, authorize the doctor, doctor’s associates, hygienists, and dental

assistants to treat my child (the patient) for the following dental or oral surgery

procedures, including the use of local anesthesia, intramuscular anesthesia, oral

sedatives, or radiographs that may be necessary to provide dental treatment.

2. I also authorize the doctors at Happy Pediatric Dentistry to consent to any changes in the

original treatment plan as recommended by the doctors or their associates.

3. In general terms, the authorized procedures may include the following as per my initials:

Please, mark your initials:

A. ______ Dental Cleaning and Fluoride Application

Procedure: The teeth are polished and any plaque or calculus (tartar) is removed. Professional

strength ﬂuoride is placed on the teeth using varnish, gel, foam, or mouth rinse.

Goals: To remove stains from teeth. To remove irritants to gingival (gum) tissue in order to provide

healthy tissues. To strengthen the teeth so that cavities are less likely.

Alternatives: Not to do procedure.

Risk: Not doing procedure can lead to an increased likelihood for development of gum disease

and cavities. Some children may end up with an upset stomach from the use of ﬂuoride.

B. ______ Application of Sealants to Dental Tissues

Procedure: The teeth are cleaned, and a clear or white-colored sealant is placed along the

grooves or ﬁssures of teeth. This is typically done without any need of anesthesia or drilling.

Goals: To ﬁll in the grooves and ﬁssures on teeth in order to minimize the chance of cavities

developing in these high risk areas.

Alternatives: Not to do procedure.

Risk: When not done, there is an increased likelihood for cavities to develop in these areas.

Unfortunately, even when correctly done, there is a chance of a sealant coming off of a

tooth (especially with habits such as ice chewing, etc.)

C. ______ Restoration of Cavities or Broken Teeth with Silver Fillings (Amalgams)

Procedure: On teeth in the back of the mouth, any decay is removed and silver ﬁllings are

placed. These are the most durable restorations (when conservative in size) and can last on

permanent teeth up to 20 years with good hygiene.

Goals: To remove decay in order to prevent it from spreading to the nerve and to

restore lost tooth structure. It is used when no nerve damage in the tooth has occurred.

Alternatives: White ﬁllings (composite). If a cavity is too large, a stainless steel or zirconia crown

is used.

Risk: These are highly successful, but can break down where the ﬁlling meets the tooth or they

can sometimes fall out.

Happy Dental Treatment Consent