Our office strongly believes in the establishment of a dental home for your child for preventive dental care in a safe and comfortable environment. In order to provide the highest quality dental care, we are required to obtain your consent before performing any dental services for your child. Please read this form carefully and we encourage you to ask us about anything you do not understand. If you have any questions, feel free to ask one of our staff members and we will be delighted to assist you.
I hereby authorize and direct Amp Orthodontics & Kids Dental, with the support of licensed dentists and or/dental auxiliaries to perform upon my child the following dental treatment or oral surgery procedures including necessary or advisable local anesthesia, radiographs (x-rays), photographs or diagnostic aids. In general terms, the dental procedures may include one, or a number of, the following:
- Cleaning of the teeth and application of fluoride.
- Application of sealants to the grooves of teeth.
- Treatment of diseased or injured teeth with dental restorations.
- Stainless steel and esthetic crowns.
- Extraction (removal) of one or more teeth.
- Treatment of diseased or injured oral tissues (hard and/or soft).
- Behavior guidance as outlined below under “Patient Management Techniques”
- Use of nitrous oxide to control apprehension.
- Space maintainer(s) to prevent shifting of teeth and/or appliance therapy.
Patient Management Techniques
We make every effort to maintain the cooperation of young patients using warmth, humor, friendliness, persuasion, gentleness and positive reinforcement. We invite you to stay with your child during the first visit and the initial examination so you will be familiar with our office and the staff providing care for your child. At future visits where your child may need restorative care, we know that many children tend to get anxious. This is why we often ask that you allow your child to come into their appointment without you. We find that this allows us to gain rapport and trust with your child. There are occasions where additional behavior management may be required to gain cooperation and prevent children from injuring themselves or dental staff. The following is a list of behavior management techniques that are recommended by the American Academy of Pediatric Dentistry.
- Tell-show-do: The dentist or assistant explains to the child what is to be done using simple terminology and shows the child what is to be done by demonstrating with instruments. The procedure is then performed in the child’s mouth as described. Praise is used to reinforce cooperative behavior.
- Positive Reinforcement: This technique rewards the child who displays any behavior that is desirable. Examples of rewards include compliments, encouragement, praises, or prizes.
- Voice Control: The attention of a disruptive child is gained through lowering or raising the tone and volume of the dentist’s voice. Care is taken not to make the child feel threatened. Content of the conversation is less important than the manner in which it is communicated.
- Nitrous Oxide “laughing gas”: It is not intended to put children to sleep, but only to relax them and minimize their anxiety.
- Mouth Props “tooth pillow”: A soft, rubber device used to assist the child in keeping their mouth open during a procedure. A MOLT might also be used. It is an external mouth opening device used in children with a strong gag reflex.
- Protective stabilization by the dental assistant: The assistant gently protects the child from movement by holding the child’s hands, stabilizing the child’s head or positioning the child safely in the dental chair. This is only used if absolutely necessary.
- Pedi-wrap: rarely used. This is a restraining device to limit a patient’s uncontrollable movements and to prevent injury. It is used as a last resort when treatment cannot be accomplished any other way and only upon consent by parent.
The treatment has been explained to me and I understand that none of the above procedures will be performed with-out discussing the necessity with me and obtaining my consent to proceed. Alternative methods of treatment, if any, have been explained to me, along with their advantages, disadvantages and risks. I am advised that good results are expected; however, the possibility and nature of complication cannot be accurately anticipated. Therefore, no guarantee, expressed or implied, can be given to me regarding this treatment. I further understand and authorize the doctor to perform any necessary treatment that in his/her judgment will be in the best interest of my child’s health, once treatment has been initiated.
Although their occurrence is rare and unpredictable, some risks are known to be associated with dental or oral surgery procedures, medication and/or anesthetics. We are required to disclose the known risk of numbness, infection, aspiration (swallowing), swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, the loss of function of organs, or scarring. I understand and accept that complications may require medical assistance, hospitalization and in very rare cases death.
I hereby state that I have read and fully understand this consent. I have been given an opportunity to ask questions regarding this consent and proposed treatment and understand that treatment and available options will always be discussed in detail prior to commencing work. I also understand that this consent will remain in effect until such time that I choose to terminate. Such termination of consent must be in writing.