WABASH VALLEY CHILDREN'S DENTISTRY INFORMED CONSENT SHEET V2

WABASH VALLEY CHILDREN'S DENTISTRY INFORMED CONSENT SHEET
PATIENT'S NAME:
1. TREATMENT TO BE DONE
Exam:
Bwx:
2 Pa's:
Fee
Initials:
Prophylaxis:
FI:
Pan:
Fee
Initials:
Fillings:
Surfaces:
Fee
Initials:
Space Maintenance
Fee
Initials:
Pulp Therapy & Treatment
Fee
Initials:
Crowns
Fee
Initials:
Sealants
Fee
Initials:
Anesthesia

Anesthesia
Initials:
Passive Security Stabilizer

Passive Security Stabilizer
Initials:
A passive security stabilizer is a measure or system that deters, delays, or prevents unauthorized access or harm without requiring continuous human intervention or active monitoring.
Extractions
Fee
Initials
2. I hereby consent to the use of reasonable force to-stabilize my child, so that examination and treatment may be performed.
Initials
3. I understand that antibiotics and analgesics and other medications can cause allergic reactions, causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
Initials
4. CHANGES IN TREATMENT PLAN
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 examination. I will be informed on any or all changes as described in #1 above before treatment is rendered.
Initials
5. I understand that dentistry is not an exact science and that therefore reputable practitioners can not properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized.
Initials
SIGNATURE:

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