Consent for Dental Treatment Under General Anesthesia
Email
example@example.com
Parent/Guardian Name
*
First Name
Last Name
Patient Name (Child)
*
First Name
Last Name
As parent/guardian to the patient, I agree to give consent to receive dental treatment under general anesthesia in the operating room at Riverview Surgical Centre.
*
Yes
No
I authorize the dentists of Chew Chew Pediatric Dentistry (Dr. Pilipowicz, Dr. Sheiny, Dr. Sihra, Dr. Alghanim) to perform the following operation or procedure: full mouth dental rehabilitation. This may include, but is not limited to (* required):
*
Rows
Yes, I agree
No, I do not agree
X-rays*
White Fillings*
Stainless Steel Crowns (metal caps)*
White Crowns (front teeth only)*
Root Canals (pulpotomy or pulpectomy)*
Extractions*
Cleaning (scaling, polish)
Fluoride
Sealants
Space Maintainers
Alternatives to the operation or procedure have been fully discussed with me by the dentists at Chew Chew Pediatric Dentistry.
*
Yes
No
I give this authorization with the understanding that any operation or procedure may involve certain risks or hazards. I understand that such risks include, but not limited to: sore throat, nausea and vomiting, respiratory and cardiovascular problems, and death.
*
Yes
No
If my dentist discovers additional treatment is required at the time of surgery; I authorize him/her to perform such operation or procedure deemed necessary.
*
Yes
No
I understand that the success of the completed treatment relies in part by my child's oral hygiene practices, diet, and other factors. Chew Chew Pediatric Dentistry recommends routine dental exams and hygiene appointments to monitor the teeth being treated today.
*
Yes
No
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Parent/Guardian
*
Submit
Should be Empty: