Please read carefully and feel free to ask about anything on this form. We will be happy to explain it further.

It is our intent that our dental care delivery be the best quality available. We are highly experienced in helping children overcome anxiety and we ask that you allow your child to accompany us through the dental experience. Dental anxiety is not uncommon in children so please try not to be concerned if your child exhibits some negative behavior; this is normal and will soon lessen with time, Studies and experience have shown that most children react more positively when permitted to experience the dental visit in an environment designed for children.

Every effort will be made to obtain your child’s cooperation through warmth, charm, humor, and understanding. When these fail, there are several behavior management techniques our office uses to minimize disruptive behavior. The techniques used are recommended by the American Academy of Pediatric Dentistry and are described below.

  • Tell-Show-Do: The dentist or assistant first explains to the child what is to be done, then demonstrates on a model or the child’s finger. Finally, the procedure is completed on the patient’s tooth. Praise is used to reinforce cooperative behavior.
  • Positive Reinforcement: This technique rewards the child who displays any desirable behavior. The rewards include compliments, praise, or a prize.
  • Voice Control: The attention of a disruptive child is gained by changing the tone, increasing, or decreasing the volume of the practitioner’s voice.
  • Mouth Props: A rubber device is gently placed in the child’s mouth to prevent either intentional or unintentional closure on the dentist’s fingers or drill.
  • Physical Restraint By Dental Team: The child is held by the doctor and dental assistant (sometimes with the help of a parent or guardian) so they cannot grab a moving drill or sharp object. They are not able to grab the practitioner’s hand while delicate work is being performed. This is for the safety of the child and to facilitate treatment.


  • Laughing Gas: Nitrous oxide (Laughing gas) is administered to calm and soothe the patient prior to a dentalprocedure. Nitrous oxide is a very safe medication that on rare occasion may cause nausea.
  • Oral Sedation: The oral medication, Versed is administered to calm and relax the patient prior to receiving dental treatment. We ask that your child not eat for six hours prior to the procedure.
  • Physical Restraint by Pillowcase Arm Restriction “Superhero Cape”: The patient’s arms are inserted in a pillowcase behind the child’s back and then the child is laid on top of the pillowcase so that their arms are restrained for their safety.

The above listed pediatric dentistry behavior management techniques have been explained to me, I understand their use, and risks/benefits/alternatives available. I have had all my questions answered and I realize I can always seek further information or revoke permission for any of these techniques.

  • By entering my name, I agree to consent.

» Download pdf version