Consent To Treat Minors

As a family dental practice, we treat the entire age span, from infants to elders. We often see pediatric patients who drive themselves to their appointments unaccompanied, or who arrive with a grandparent or other care provider who is not their parent/guardian. When this occurs, we assume you, as their parent/guardian, are entrusting us to care for them and understand that we will provide the appropriate, prescribed care for their situation.

This may include:

• reviewing medical and dental histories,
• nutrition counseling
• smoking (nicotine/tobacco/marijuana) cessation counseling,
• HPV vaccination discussion (*see below),
• taking appropriate radiographs (x-rays),
• performing head, neck, and oral examinations,
• cleaning the teeth,
• treating the teeth with fillings, sealants, fluoride varnish,
• extracting infected or retained primary teeth,
• extracting teeth as requested by an orthodontist for space optimization,
• abricating oral appliances, including sports guards, night guards, space maintainers, and more.

While this is not an exhaustive list, it does describe most procedures we may routinely provide for children, depending on their individualized needs and circumstances.

By signing below, you are giving us permission to provide the appropriate care for your child even if you are not present to discuss the case. If there are any treatments that you do not consent to, please indicate below. If you wish to discuss your child’s routine care, please attend their appointments with them, or communicate with our staff in advance to ensure that we are addressing your questions and concerns. Thank you for helping us to provide the best care for your child.