State law requires us to obtain your consent for contemplated dental treatment. Please read this form carefully and ask about anything you do not understand. We will be glad to explain it.
1. After consultation with Dr. Evan Reed, Dr. Lindsey Reed, Dr. Amy LeCave, Dr. Danielle West and/or Dr. Jaime Orrick, and an explanation about any proposed procedure, I hereby authorize and direct Dr. Evan Reed, Dr. Lindsey Reed, Dr. Amy LeCave, Dr. Danielle West and/or Dr. Jaime Orrick, assisted by other dental auxiliaries of his/her choice to perform upon my child (or legal ward) the following dental treatment or oral surgery procedure(s) including the necessary or advisable local anesthesia radiographs (x-rays) or diagnostic aids.
2. In general terms the dental procedures may include one or a combination of the following:
- Cleaning of the teeth and the application of topical fluoride
- Dental radiographs
- Application of plastic "sealants" to the grooves of the teeth
- Intraoral photographs of the teeth
- Treatment of disease or injured teeth with dental restorations
- Replacement of missing teeth with a dental prosthesis
- Removal (extractions) of one or more teeth
- Treatment of disease or injured oral tissues (hard and/or soft)
- Treatment of malposed (crooked) teeth and/or developmental abnormalities
Alternative methods of treatment, if any, will also be explained to me, as will the advantages and disadvantages of each. We 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 result of the treatment or as to the cure.