I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize Drs. Nielson and Smith and/or dental staff to perform the necessary dental services my child may need. This may include exams, radiographs, cleanings, topical fluoride treatment, restorative dentistry, oral surgery or limited orthodontics. In order to perform such treatment, our team may recommend the use of local anesthesia (numbing) and/or nitrous oxide (laughing gas), conscious sedation or general anesthesia.