Mobile Dental Child Treatment Consent Form

NEW Health's Mobile Dental - Child Restorative Treatment Consent Form
Mobile Dental Treatment Authorization

Your child was previously seen on NEW Health's Mobile Dental Clinic and has already received a dental examination under the signed Consent to Treat a Minor. Based on the findings from that visit, additional dental treatment is recommended. This form authorizes NEW Health to provide the treatment outlined in your child's treatment plan during a return visit to the Mobile Dental Clinic.
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Enter School Name
Grade
Parent or Legal Guardian Name

First NameLast Name
Parent of Legal Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Health Updates
Have there been any changes in your child's health, medications, or allergies since the last dental visit?
If Yes, Please Explain:
Questions for the Dental Team
Would you like a member of the dental team to contact you before treatment?

Treatment Authorization

I authorize the NEW Health dentist and dental team to provide the recommended restorative dental treatment identified in my child's treatment plan.

The recommended treatment may include:

• Tooth-colored fillings or other appropriate restorative treatment
• Local anesthetic (numbing medication)
• Placement of a protective dental material or temporary restoration when clinically necessary.
• Other routine procedures reasonably necessary to safely complete the planned restorative treatment.

If the dentist determines that substantially different treatment is needed, NEW Health will attempt to contact me before proceeding, unless immediate action is necessary to protect my child's health and safety.
Benefits and Possible Risks

The purpose of restorative dental treatment is to treat tooth decay, help prevent the condition from worsening, reduce the risk of pain or infection, and support my child's oral health.

Possible risks or side effects may include:

• Temporary discomfort, pain, or tooth sensitivity
• Temporary numbness of the lips, cheeks, tongue, or surrounding tissues
• Accidental biting or injury to numb tissues
• Bruising, tenderness, or swelling at the injection site
• Allergic or unexpected reactions to dental materials or medications
• A filling that may later need adjustment, repair, or replacement
• Decay that is deeper or more extensive than originally identified
• The need for additional treatment if the condition of the tooth changes
• Rare injury to the gums, tongue, cheek, teeth, or surrounding tissues
• Rare swallowing of a small dental material or instrument

While every effort will be made to provide safe and effective care, no guarantee can be made regarding treatment outcomes.
Required Parent/Guardian Acknowledgment
Electronic Signature Statement

By signing below, I confirm that:

• I am the child's parent or legal guardian, or I am legally authorized to consent to the child's dental care.
• The information provided is accurate to the best of my knowledge.
• My electronic signature has the same legal effect as my handwritten signature.
• I voluntarily authorize the treatment described in this form.
Relationship to Child
If Other, Please Describe
Best Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Electronic Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

NEW Health's Mobile Dental - Child Restorative Treatment Consent Form

Mobile Dental Treatment Authorization

Health Updates

Questions for the Dental Team

Required Parent/Guardian Acknowledgment