• Informed Consent for Dental Cleaning and Exam

  • Please read this form carefully. I hereby authorize and direct Dr. D’Audra M. Cole, assisted by dental auxiliaries, to perform upon my child (or legal ward for whom I am empowered to consent) the following dental procedures:

    In general terms the dental procedures will include:

    • Cleaning of the teeth
    • Dental examination
    • Use of patient behavior management techniques to help safely accomplish the dental procedure when necessary.

    I also authorize Dr. D’Audra M. Cole to use photographs, radiographs, other diagnostic materials and treatment record for the purpose of teaching, research and scientific publications.

    I understand further that I have the right to be provided with answers to questions, which may arise during the course of my child’s treatment.

    I understand that I am free to withdraw my consent to treatment at any time and that this consent will remain in effect until such time that I choose to terminate it.

  • Informed Consent for Fluoride Varnish

  • Fluoride is effective in preventing and reversing the early signs of dental caries (tooth decay). Researchers have shown that there are several ways through which fluoride achieves its decay preventive effects. Fluoride incorporates into the tooth structure making it stronger resulting in teeth that are more resistant to acid attacks. Fluoride also acts to repair or remineralize areas in which acid attacks have already begun.

    Fluoride application is an important part of your child’s comprehensive preventative program at Frederick KiDDS Pediatric Dentistry. Fluoride not only helps prevent new decay from developing, it also helps protect existing dental work so that fillings are replaced less frequently, decreases sensitivity, makes teeth last longer and saves you money! Fluoride is most effective when applied after the dental cleaning after all the plaque and build up have been removed from the tooth’s surface. It is our office protocol to apply fluoride varnish at each routine care appointment for your child to receive maximum benefit.

    In April of 2018 the National Toxicology Program published a study in the scientific journal entitled Neurotoxicity Research which stated that “Researchers found no link between fluoride exposure and adverse health effects.The study, sponsored by the NTP, headquartered at the National Institute of Environmental Health Sciences of the National Institutes of Health, reported no observed fluoride exposure-related differences in motor, sensory or learning and memory performance in rats. Researchers also found no exposure-related pathology in the heart, liver, kidney, testes, seminal vesicles or epididymides.”

    Fluoride varnish is formulated to stick to tooth surfaces to avoid swallowing preventing toxicity and upset stomach. Occasionally children may feel nauseous due to the flavor of the fluoride varnish.

    It is your choice whether or not to have fluoride placed for your child during their dental cleaning appointments. Please indicate your choice below and let the dentist, hygienist, or staff member know if you change your mind at any time.

  • Informed Consent for Dental X-rays

  • Dental x-rays allow the dentist to diagnose and treat conditions that cannot be detected during a clinical examination. Dental x-ray films detect much more than cavities. For example, x-rays may be needed to assess erupting teeth, diagnose bone diseases, evaluate the results of an injury, or plan orthodontic treatment. If dental problems are found and treated early, before they become visible or painful, dental care is much more comfortable and affordable. Dental x-rays are a part of a comprehensive oral examination.

    Per the recommendation of the American Academy of Pediatric Dentistry, Bitewing x-rays (cavity detecting x-rays) are recommended every 6-12 months for a patient with dental cavities or at increased risk for cavities or at 12-24 months for patients with no history of dental cavities where interproximal (in between) tooth surfaces are not visible. Select periapical x-rays may be taken to address specific problems such as pain, unerupted teeth, injury, etc. Additionally, a panoramic (growth and development) x-ray may be taken between the ages of 4-12 years and possibly between the ages of 14-20 when imaging of wisdom teeth is needed. The dose of radiation is minimal from dental x-rays, and all necessary precautions will be taken to ensure exposure is minimal (lead apron, collar and digital imaging).

    It is the policy of Frederick KiDDS Pediatric Dentistry to examine each child and identify their individual need for dental imaging. You have the right to refuse dental x-rays for your child. Frederick KiDDS Pediatric Dentistry reserves the right to dismiss any patient or family that denies necessary dental x-rays after three refusals as this limits the ability of the dentist to identify and diagnose any dental conditions. No dental treatment will be completed without dental x-rays. It is at the discretion of the dentist to treat if the patient is unable to cooperate for dental x-rays and exceptions can be made in such cases. Also, dental x-rays received from a previous office may not always be diagnostic or useful, they can even be blurry or inappropriate for the patient’s age or dental treatment needs. In those instances new x-rays may need to be taken.

    It is your choice whether or not to have dental x-rays for your child Please indicate your choice below and let the dentist, hygienist, or staff member know if you change your mind at any time.

  • By entering my full name, I agree to consent.

» Download pdf version