NEW PATIENT FORMS

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.
Signature of parent or guardian*

Clear
Date*

MonthDayYear
Date

Acknowledgment of Receipt of Privacy Practices

Cara L Donley, DMD PC 327- B Boston Post Road Sudbury, MA 01776
I have received or am aware there is a copy of this office's Notice of Privacy Practices on the website and in the office.*

YesNO
Parent Signature*

Clear
Date*

MonthDayYear
Date

Informed consent for Dental Procedures
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.
TREATMENT TO BE PROVIDED. I understand that during my child's course of treatment as a patient the following may be provided: Examinations, Preventive services, dental radiographs ( x-rays) , restorative treatment ( Fillings), and extractions.*

YesNO
DRUGS/MEDICATIONS. I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues: pain, itching, vomiting, and/or anaphylactic shock ( severe reaction)*

YesNo
CHANGES IN TREATMENT PLANS. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. I give the dentist permission to make any/ all changes and additions as necessary.*

YesNo
BILLING. I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable.*

YesNO
Parent Signature*

Clear
Date*

MonthDayYear
Date

Should be Empty:

Cara L Donley DMD PC Pediatric Dentistry

MEDICAL HISTORY

Acknowledgment of Receipt of Privacy Practices

Informed consent for Dental Procedures