PEDIATRIC DENTISTRY CONSENT FOR DENTAL PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

1. State Law requires us to obtain your consent to your child’s contemplated dental treatment or oral surgery. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain it. I hereby authorize and direct Dr. Pope- Ozimba assisted by other dental and/or dental auxiliaries of her choice, to perform upon my child (or legal word for whom I am empowered to consent) the following dental treatment or oral surgery procedure(s).
2. In general terms the dental treatment or procedures will include:
   1. Radiograph (x‐rays) of the teeth and jaws.
   2. Cleaning of the teeth and the application of topical fluoride.
   3. Application of plastic “sealants” to the grooves of the teeth.
   4. Use of local anesthesia to numb the teeth and tissues.
   5. Treatment of diseased or injured teeth with dental restorations (fillings).
   6. Removal (extraction) of one or more teeth.
   7. Treatment of diseased or injured oral tissues (hard and / or soft).
   8. Treatment of malposed (crooked) teeth and/or oral development or growth abnormalities.
   9. Use of sedative drugs to control apprehension and/or disruptive behavior.
   10. Use of General Anesthesia to accomplish the necessary treatment.

The nature and purpose of the treatment and procedures have been explained tome in general terms by Dr. Pope‐Ozimba and/or assistant. Alternates purpose of the treatment and procedures have been explained to me, as have their advantages and disadvantages, the risks, consequences and probable effectiveness of each, as well as the prognosis if no treatment is provided. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore there can be no guarantee as expressed or implied either as to the rest of the treatment or as to cure. I further authorize the doctor to perform other dental services that in her judgment are advisable for my child or legalward, with the exception of (if none so State).

3. I also authorize Dr. Pope‐ Ozimba to use photographs, radiographs, and other diagnostic material and treatment records for the purpose of teaching, research, and scientific publications.
4. Although their occurrence is not frequent, some risks and complications are known to be associated with dental or oral surgery procedures. The most common complication associated with pediatric dental treatment includes nausea following the administration of topical fluoride and children biting and injuring the tongue or lip following administration of local anesthesia. Less common complications includes the risks of numbness, infection, swelling prolonged bleeding, discoloration, vomiting, allergic reactions, swallowing or aspiration of a crown form, and extracted tooth or gauze packing; injury to the tongue and/or lips, damage to and possible loss of existing teeth and/or restorations (fillings), injury to nerves near the treatment site and fracture of a tooth root which may require additional surgery for its removal. For children with heart disease, the risk of subacute bacterial endocarditic (heart infarction) following dental treatment exists, therefore antibiotics will be prescribed before and following treatment, to minimize risk. I further understand and accept that complications may require additional medical, dental, or surgical treatment and may require hospitalization.

I hereby state that I have read and understand this consent form, that I have been given an opportunity to ask questions I might have, and that all questions about the procedure or procedures have been answered in a satisfactory manner; and I understand further that I have the right to be provided with answers to questions which may arise during the course of my child’s treatment.

I further understand that I am free to withdraw my consent to treatment at any time, and that this consent will remain in effect until such time that I choose to terminate it. 

I certify that I explained the above procedures to the parent or legal guardian before requesting their signature

To the parent / guardian of:

As a concerned dentist, I would like to discuss with you the methods of managing your child’s behavior during treatment. While children are usually cooperative and brave, sometimes they can be frightened by the equipment and the unknown experience. This is especially true for children younger that three years, but it also hold true to some older children. In order to treat you child safely, we may have to use these aids:

• Mouth Rester, to help hold the child’s mouth open to provide the dentist with better access and prevents the child from biting down on a working drill. If a child falls asleep during the procedure, the Mouth Rester will enable the dentist to continue to work without waking the child.
• Holding Assistant, helps secure the child, protecting and positioning him on the dental chair. In addition, the assistant may comfort, massage, and soothe the child. This person may be you, parent / guardian.
• Papoose boards, Pedi‐Wraps and/or Pillow Case, these are protective restraining stabilizers for limiting your child’s movement to prevent injury to the child and the providers. Protective stabilization enables the dentist to provide the necessary dental treatment. This child is wrapped in these stabilizers and placed in a reclined dental chair.

Note: Before giving us permission to use these aids, please feel free to ask questions or express any concerns. Please rest assure that you child will receive optimal treatment with us. These behavioral management aids are only used when necessary. Thank You. 

This listed pediatric dentistry behavior management technique has been explained to me by Dr. Jeannette Pope-Ozimba. Alternate techniques for treatment, if any has also been explained to me, as have the advantages and disadvantages of each.

I hereby authorized and direct Dr. Pope-Ozimba assisted by other dentist and/or dental auxiliaries of her choice, to utilize the behavior management techniques listed on the reverse side of this form to assist on the provision of the necessary dental treatment as previously explained to me by Dr. Pope-Ozimba for my child (or legal ward) for whom I am empowered to consent with the exception of (in none, so state):

I also understand that there will be a $66.00 behavior management fee per 15 minutes during treatment. Medicaid or Peachcare does not cover this fee. Payment will be due at the time of services. No exceptions!!!!!!!!!!

I hereby acknowledge that 1 have read and understand this consent form. I have been given the opportunity to ask questions that I might have, and all questions about the behavior techniques described have been answered in a satisfactory manner, and I further understand that I have the right to be provided with the answers to questions which may arise during the course of my child's treatment.

I further understand that I am free to withdraw my consent to treatment at any time and this consent shall remain in effect until I choose to terminate it.

I certify that I explained the above procedure and techniques to the parent or legal guardian before requesting their signature.

*You May Refuse to Sign This Acknowledgement* 

I, , have received a copy of this office’s Notice of Privacy Practices. 

For Office Use Only   

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

I am the (parent or guardian) of (name of child) who is a minor child and I authorize examination and treatment as necessary by or under the supervision of Dr. Pope‐Ozimba. This includes exposure of radiographs as necessary, use of local anesthetic, reasonable restraints as needed, and use of appropriate medicaments and material for such treatment.

I give you office consent to discuss treatment concerning the above mentioned minor child to the following individual(s): 

I understand that the above person(s) can not sign any consent forms pertaining to treatment for the above mentioned minor child. 

I READ AND UNDERSTAND THE ABOVE INFORMATION AND THE INFORMATION GIVEN TO ME VERBALLY. BY MY SIGNATURE I CONSENT TO THE TREATMENT DESCRIBED IN THIS CONSENT FORM.