Today’s date:

INFORMATION MANAGEMENT OF BEHAVIOR AND CONSENT FOR TREATMENT
Our desire is to provide quality treatment in caring environment for you and your child. We provide the following
information in order to familiarize you with our office guiding principles. Please feel free to discuss any questions you may
have with one of our team members.
We ask that parents accompany their child back to the examination room for their first visit. A complete diagnosis and any
necessary x-rays will be completed. The doctor will discuss your child’s diagnosis and recommend a plan of treatment.
On subsequent visits, parents may remain in the reception area or accompany your child to the treatment area. We have
found that we may be able to establish a better rapport and keep all of our attention focused on the child when the parent
is not present, and on occasion may ask you to remain in the reception area. One of our dental assistants will remain with
your child at all times. When treatment has been completed the dentist or a dental assistant will explain to you what was
done, as well as what the next treatment will involve. At any visit if you wish to speak to the dentist about anything, please
tell the dental assistant and the doctor will be happy to meet with you.
We utilize a number of behavior management techniques to help children through their treatment. All of the techniques
we use are recognized by the American Academy of Pediatric Dentistry as effective and acceptable. Our goal is to
provide the treatment in an efficient, safe manner while hopefully instilling a positive dental attitude in the child.
During treatment, nitrous oxide (laughing gas) is frequently used to reduce anxiety. (We call the small rubber mask “Mr.
Nose”.) Nitrous oxide is very safe, has few side effects with the exception of nausea in a small percentage of children,
and has no lingering effects after the visit. For our especially fearful patients, the doctor may suggest that your child be
given a mild sedative prior to treatment. The pre-medication is generally liquid Demerol and Atarax given one hour prior
to the appointment as a sedative and relaxant. Our goal is not to put your child to sleep; rather, to help relax them and
make him/her feel happy and more comfortable with the visit.
In order to provide quality dental work and reduce the risk of injury to a child, it is absolutely necessary that the child
remain still during the treatment. Despite our efforts to calm a child with reassurances, showing the instruments and
explaining the noises they will hear, at times we encounter difficult management problems. If a child is cooperating poorly
it may be necessary to use one or more of the following behavioral management techniques to facilitate treatment.
IMMOBILIZATION: So the child does not cause injury to themselves by trying to grab the doctor’s hand during treatment,
some children may need to have their hands held by an assistant during certain parts of the procedure to help them sit
still.

VOICE CONTROL: In order to gain the child’s attention, instruction is given in a firm tone of voice.
HOSPITALIZATION: This may be recommended for very young children or those children with significant medical or
behavioral problems. This is required for very few children and will be thoroughly discussed with you if other options can
not be used successfully.
Your child’s best interests are most important to us. We will seek to conservatively manage the behavior of your child
and help him/her to accept dental care in a positive, non-threatening environment. We hope to promote good, long-term
attitudes towards dentistry, oral health, and self. Thank you for trusting us to treat your child.
If you have questions about any of this information please speak with one of our team members or doctors. I hereby authorize and direct Children's Dental Care and Orthodontics to perform on my child necessary dental treatment as presented in the treatment plan, including the use of necessary or advisable local anesthesia, radiographs (x-rays), diagnostic aids, and or/nitrous oxide. 1. I have read the preceding information regarding behavior management techniques and understand that at times it may be necessary for the dentist to utilize these management therapies. I also understand that if I have any questions about the behavior management techniques, I can discuss then with the dentist prior to treatment. 2. I understand that specific dental/surgical procedures will be explained when I am presented my child’s treatment plan. Alternate methods, if any, will also be explained to me, as will the advantages and disadvantages of each. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and, therefore, there can be no guarantee, expressed or implied, as to the result of the treatment or as to cure. 3. Although their occurrence is infrequent, there are some inherent risks that accompany Local anesthetic (such as Lidocaine or Novocaine) is used to make teeth numb so that dental treatment will not hurt. When it is used, the child may chew the cheek, lip, or tongue while they are numb. Soreness of the lower jaw (Trismus) may also occur following an injection. Although not common, excessive bleeding, pain, swelling may occur after the removal of a tooth. Temporary or permanent numbness of the tongue or lip (paresthesia) can also occur. Nitrous oxide (laughing gas) is used to help relax children who are particularly nervous so that the treatment can be done properly. Though infrequent, the child may experience nausea or vomiting with its use. I hereby state that I have read and understand this consent, and that all questions about the procedure(s) have been answered to my satisfaction. I understand that I have the right to be provided with answers to questions that may arise during the course of my child’s treatment. I further understand that this consent will remain in effect until such time that I choose to terminate it. Patient’s Name: _______________________________ Date: __________ Time: _________ Parent/Guardian’s Signature: ____________________________________________________ Relationship to patient: _________________________________________________________ Signature of Witness: __________________________________________________________

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