I/We, Guardian/Father's First Name Guardian/Father's Last Name and/or Mother's First Name Mother's Last Name , having full custody of Child's First Name Child's Last Name , with date of birth on Date and with residence at Street Address Address Line 2 City State Zip , do hereby authorize our/my child to participate or undergo dental treatment.I/We have been informed about the various procedures which may or may not be used for my/our child's treatment. Among the procedures are the:Use of SealantsSealants help protect only the surface of the teeth and do not guarantee free teeth from any cavity. I/We understand that sealants are not permanent and may deteriorate. Topical AnesthesiaThese help in the numbing of the tissue surface for the purpose or easing pain and discomfort on the area where treatment is to be done. Temporary FillingsThe use of Temporary Fillings is needed for immediate restoration and is usually used for purpose of preparation for a more extensive treatment plan.Stainless Steel Crowns and Strip CrownsStainless steel crowns and strip crowns cover a tooth that prevents it from weakening or breaking. This is done in cases where a child's tooth is weak. To prevent it from further breaking by covering the whole tooth. The difference is that stainless steel crowns are usually used for molars whereas strip crowns are used for incisors or canine. They differ in color as well. As the name implies, stainless steel crowns are metallic in color while strip crowns use enamel that resembles the color of the teeth. Nerve Treatment (Pulpectomy/Pulpotomy)In cases where the decay reaches the nerves, treatment is conducted to prevent further damage or decay called pulpectomy or pulpotomy. This procedure is used in order to prevent the further decaying of the tooth and the tissues surrounding it from becoming infected.Tooth ExtractionThis is the removal of the tooth of the child. In some cases, a child's gums may be swollen or might continue to bleed after treatment. Thus, it is important that parents understand and comply with the post-operative treatment instructions given to them for their child.
Use of Nitrous OxideThere are certain cases that may be needed that children be given nitrous oxide prior to treatment, especially if a child shows nervousness or fear to dental treatment. A child may be given this to ease them down. This is a mild anti-anxiety sedative, thus, will help the child to be relaxed. This will be delivered through the child's nose and will only last 3-5 minutes upon breathing or oxygen or room temperature air.
Parental Understanding and Consent
The following information above has been explained to me/us and I/we understand that there are various risks involved in the treatment. There might be cases where there would be changes in the procedure due to various conditions or discoveries prior to treatment. There might be cases where no treatment shall be recommended. I/We have had the opportunity to ask questions and all of which were answered to me and properly explained. I/We agree for my/our child to be treated under the clinic in accordance to the treatment plan I/we have authorized.Treatment: 1 Signature of Father: Signature Date signed: Date Signature of Mother: Signature Date Signed: Date