Consent for Dental Treatment
Please read this form carefully before signing. Prior to starting any treatment, we will confirm that you understand treatment options, including risks, benefits, and alternatives. If you have any questions, please ask.
In order for our dental team to properly diagnose your child’s dental and oral health condition, the following may be necessary
- Dental and oral examination
- Radiographs (x-rays) to diagnose and treat dental conditions as well as growth and development
To optimize your child’s oral health condition and to reduce the risk of disease and dental decay, the following treatment may be rendered
- Prophylaxis (cleaning)
- Fluoride application
- Dental Sealants
Common dental treatment for pediatric patients includes
- Composite restorations (white fillings)
- Stainless steel crowns (for teeth that have significant decay and/or were treated with pulpotomies)
- Pulp therapy (nerve treatment may include pulpotomies or pulpectomies [root canals] to treat teeth with deep decay or that were traumatized)
- Extraction (may result in damage to adjacent and/or permanent teeth, pain, swelling, bleeding, nerve/jaw damage)
- Space maintainer appliances - appliances made to hold space when primary (baby) teeth are lost early
- Nitrous Oxide “laughing gas” Inhalation – may be used to help a child relax and cope with dental treatment. May result in nausea, vomiting, tingling of the hands and feet.
Dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Fini will provide an environment that will help children learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments, and using variable voice tones.
Restraint / Immobilization–for the patient’s safety to reduce unwanted movement, Dr. Fini and her staff may need to use restraint devices (for example, mouth props) or may need to physically hold the child still. Restraint will only be used when absolutely necessary.
Risks of Refusing Treatment
You have the right to refuse treatment; however, delayed treatment may allow for undiagnosed conditions, progression of dental disease, abscess formation, infection, fever, risk of damage to permanent teeth.
Complications of Dental Treatment
The usual and most frequent risks or complications occurring from dental treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury or permanent numbness, and allergic reactions.
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