Consent for Treatment Form

Please read this form carefully before signing.Prior to starting any treatment, we will confirm that you understand treatment options, including risks, benefits, and alternatives. If you have any questions, please ask.

Diagnosis
In order for our dental team to properly diagnose your child's dental and oral health condition, the following may be necessary
-Dental and oral examination
-Radiographs (x-rays) to diagnose and treat dental conditions as well as growth and development
-Photographs

Prevention
To optimize your child's oral health condition and to reduce the risk of disease and dental decay, the following treatment may be rendered
-Prophylaxis (cleaning)
-Fluoride application
-Dental Sealants

Treatment - Common dental treatment for pediatric patients includes
-Composite restorations (white fillings)
-Stainless steel crowns (for teeth that have significant decay and/or were treated with pulpotomies)
-Pulp therapy (nerve treatment may include pulpotomies or pulpectomies [root canals] to treat teeth with deep decay or that were traumatized)
-Extraction (may result in damage to adjacent and/or permanent teeth, swelling, bleeding, nerve damage, damage to the jaw, pain)
-Space maintainer appliances - appliances made by dental laboratories to hold space when primary (baby) teeth are lost early
-Nitrous Oxide "laughing gas" Inhalation - may be used to help a child relax and cope with dental treatment. May result in nausea, vomiting, tingling of the hands and feet.

Behaviour Management
Dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Goldenberg will provide an environment that will help children learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments, and using variable voice tones.
Restraint / Immobilization-for the patient's safety to reduce unwanted movement, Dr. Goldenberg and her staff may need to use restraint devices (for example, mouth props) or may need to physically hold the child still. Restraint will only be used when absolutely necessary.

Risks of Refusing Treatment
You have the right to refuse treatment; however, delayed treatment may allow for undiagnosed conditions, progression of dental disease, abscess formation, infection, fever, risk of damage to permanent teeth.

Complications of Dental Treatment
The most common complications of pediatric dental treatment are: prolonged numbness, bruising following local anesthetic use. Less common complications include vomiting, nerve injury, and allergic reactions.