GENERAL CONSENT

GENERAL CONSENT
  • e - Dentistry

    Ph.xxx-xxx-xxxx

    Ph.xxx-xxx-xxxx

    edentalforms@gmail.com

  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 50.
  • I hereby authorize and direct the dentists of THE LITTLE TEETH WORKSHOP and/ or 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 use of any necessary or advisable local anesthesia, radiographs (x- rays) or diagnostic aids.
    1. Cleaning of teeth and the application of topical fluoride.
    2. Application of plastic “sealants” to the grooves of the teeth.
    3. “Treatment of diseased or injured teeth with dental restorations (fillings).
    4. Replacement of missing teeth with dental prosthesis.
    5. Removal (extraction) of one or more teeth.
    6. Treatment of diseased or injured oral tissue (hard and/or soft)
    7. Postponing or delaying treatment at this time.
    8. Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.
    I understand that there are risks involved in this treatment and hereby acknowledge that these risks have been explained to me, that I have had an opportunity to ask questions regarding the treatment and the risks and that I fully understand the same. By typing my name below I give consent to The Little Teeth Workshop and Dr.Iyer to perform the necessary dental procedures needed.