To the best of my knowledge, the questions on this medical and dental form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my resposibility to inform the dental office of any changes in medical status.
YOu, the parent, has the right to accept or reject dental treatment recommended for your child by the dentist. Prior to consenting for treatment, you should carefully consider the anticipated benefits and commonly known risks fo the recommended procedure, alternative treatments, or the option of no treatment.
Do not consent to treatment unless andunitll you diuscss potential benefits, risks and complications with your child's denitst and all your questions are answered. By consenting to the treatment, you are acknowledging your wllinigness to accept known risks and complications, no matter how alight the probability of occurrence.
It is very important that you provide your child's dentist with accurate information, beofre, during, and after treatment. It is equally impoirtant that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your child's dentist, you may increase the chances of a poor outcome.
Please read and respond to acknowledgements below and SIGN at the bottom of the form.