Please read this form carefully and ask about anything that you do not understand. 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 treatment or oral surgery procedures:

In general terms the dental treatment or procedures will include:

  • Radiographs (xrays) of the teeth and jaws
  • Cleaning of the teeth and application of topical fluoride
  • Application of sealants to the grooves of the teeth
  • Use of local anesthesia to numb the teeth and tissues
  • Treatment of diseased or injured teeth with dental restorations (fillings)
  • Removal (extraction) of one or more teeth
  • Treatment of diseased or injured oral tissues (hard and/or soft)
  • Use of patient behavior management techniques to help safely accomplish the necessary dental procedure

Dr. D’Audra M. Cole has explained the nature and purpose of the treatment and procedures to me in general terms. Alternate procedures or methods of treatment, if any, have also been explained to me, as have their advantages and disadvantages, the risks, consequences and probable effectiveness of each, as well as the prognosis if no treatment is provided.

I am advised that although good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee expressed or implied either as to the result of the treatment or as to cure. I further authorize the doctor to perform other dental services that in their judgment are advisable for my child or legal ward.

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.

Although their occurrence is not frequent, some risks and complications are known to be associated with dental or oral surgery procedures. The most common complications associated with pediatric dental include: nausea following the administration of topical fluoride and children biting and injuring their tongue or lip following the administration of local anesthesia. Less common complications include the risks of numbness, infection, swelling, prolonged bleeding, discoloration, vomiting, allergic reactions, swallowing or aspiration of a crown or an extracted tooth or gauze packing. Injury to the tongue and/or lips, damage to and possible loss of existing teeth and/or restorations, injury to nerves near the treatment site and fraction of a tooth root which may require additional surgery for its removal. For children with heart disease, the risk of sub acute bacterial endocarditis (heart infection) following dental treatment exists; therefore antibiotics will be prescribed before treatment. I further understand and accept that complications may require additional, medical, dental or surgical treatment and may require hospitalization.

I hereby state that I have read and understand this consent form that I have been given an opportunity to as any questions I may have and that all questions about the procedure or procedures have been answered in a satisfactory manner. 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 further 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.

Consent for Dental Procedure and Acknowledgement of Receipt of Information

  • By entering my name, I agree to consent.

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