Consent to Treat | Huntersville Smiles Orthodontics & Kids Pediatrics

  • Consent to Treatment

    Our office specializes in the dental health of children. We strongly believe in the early establishment of a dental home for your child that provides a safe and comfortable environment. To provide the best dental care, your consent regarding treatment, including preventative services, is required. Please read this form carefully, and we encourage you to ask any questions you may have.  

    I authorize Huntersville Smiles, with the support of a licensed dentist and/or dental auxiliaries, to perform the following dental treatment and/or oral surgery procedures for my child: necessary or advisable local anesthesia, fluoride radiographs (x-rays), photographs or diagnostic aids. Dental treatment may include one, or a number, of the following:

    • Cleaning of the teeth and application of fluoride
    • Application of sealants to the grooves of teeth
    • Treatment of diseased or injured teeth with dental restorations
    • Stainless steel crowns
    • Extraction (removal) of one or more teeth
    • Treatment of diseased or injured oral tissues (hard and/or soft)
    • Treatment of malposed (crooked) teeth and/or developmental abnormalities with fixed or removable orthodontic appliances
    • Behavior guidance using mouth prop, teel-show-do method, and/or voice control
    • Protective stabilization including holding my child or the use of a papoose board
    • Use of sedation medications and/or nitrous oxide to control apprehension
    • Space maintainer(s) to prevent shifting of teeth

    I understand that during treatment it may be necessary to change or add procedures based on health of tooth and/or child’s behavior. I give permission to the dentist to make any/all changes he/she deems necessary. The treatment has been explained to me and I understand that none of the above procedures will be performed without discussing the necessity with me and obtaining my consent to proceed. Alternative methods of treatment, if any, have been explained to me, along with their advantages, disadvantages, and risks. I am advised that good results are expected; however, the possibility and nature of complication cannot be accurately anticipated. Therefore, no guarantee, expressed or implied, can be given to me regarding this treatment.

    Although their occurrence is rare and unpredictable, some risks are known to be associated with dental or oral surgery procedures, medications, and/or anesthetics. We are required to disclose the known risk or numbness, infection, aspiration (swallowing), swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, the loss of function of organs, or scarring. I understand and accept that complications may require medical assistance, hospitalization and in very rare cases death.

    The American Academy of Pediatric Dentistry recommends fluoride be applied twice per year to help aid in the formation of tooth enamel, to repair early stages of tooth decay, and to help prevent decalcification. For this reason, please be aware that this will be applied at each cleaning unless otherwise notified.

  • Acknowledgement Of Receipt Of Content to Treatment

    I hereby state that I have read and fully understand this consent, I have been given an opportunity to ask questions regarding this consent and proposed treatment and understand that treatment and available options will always be discussed with me in detail prior to commencing work. I also understand that this consent will remain in effect until such time that I choose to terminate. Such termination of consent must be in writing.
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