Dental Treatment Consent Form printable pdf download

CAMINO HEALTH CENTER

DENTAL TREATMENT CONSENT FORM

Please read and initial the items checked below and sign

Patient Name:

the section at the bottom of this page.



1. WORK TO BE DONE

I understand that my child is having the following work done: Fillings: ________ Crowns: ________ Extractions: ________

Root Canals: ________ Pulpotomies: ________ Space maintainers: ________ Impacted teeth removed: _______________

Other: ____________________________________

( Initials: ___________)



2. DRUGS AND MEDICATIONS

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of

tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

( Initials: __________)



3. CHANGES IN TREATMENT PLAN

I understand that during 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, the most common being root canal therapy following routine

restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

( Initials: ___________)



4. REMOVAL OF TEETH

Alternatives to removal have been explained to me (root canal therapy, crowns) and I authorize the Dentist to remove the

Following teeth _________________________________ and any others necessary for reasons in paragraph #3. I understand

removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I

understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss

of feeling in the teeth, lips, tongue and surround tissue (Paresthesia) that can last for an indefinite period of time (days or

months) or fractured jaw. I understand my child may need further treatment by a specialist or even hospitalization if

complications arise during or following threatment, the cost of which is my responsibility.

( Initials: ___________)



5. ENDODONTIC TREATMENT (ROOT CANAL and PULPOTOMY)

I realize there is no guarantee that root canal treatment will save my child’s tooth, and that complications can occur from the

treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily

affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following

root canal treatment (apicoectomy).

( Initials:____________)



6. Nitrous Oxide

I authorize the doctor to administer by nose mask nitrous oxide to my child during his/her dental treatment. Nitrous oxide is

used to help my child relax and make him/her less anxious. It is possible that my child may experience nausea as a result of the

nitrous oxide.

(Initials :____________)

I understand that dentistry is not an exact science and that, therefore, no practitioner can fully guarantee absolute results. I

acknowledge that no guarantee or assurance has been made by anyone regarding the 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 the proposed treatment.

Signature of Parent/Guardian:

Date:

Dental Treatment Consent Form

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