Texas State Law requires that we obtain your written informed consent for any treatment given your child as a legal minor. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain more.
It is the policy of Toothbud Pediatric Dentistry to inform parents of all procedures contemplated for your child. At each examination appointment, we will identify any dental treatment needed and describe this to you and your child. Each check-up visit consists of oral hygiene instructions, cleaning of the teeth, as needed topical
application of fluoride, as needed radiographs/x-rays, examination of the mouth and the bite. Any other treatment recommendations such as fillings, crowns, extractions, etc. will be performed after obtaining your permission and most likely at a separate appointment.
I hereby authorize Dr. Ann Dimick assisted by members of her dental practice to perform upon my child, the following records as needed which may include photographs, radiographs, other diagnostic materials and treatment for the purpose of diagnosis and treatment.
I authorize Dr Dimick to use in general terms the dental procedures with consent prior to performing such dental treatment such as behavior management, nitrous oxide, fillings, crowns, extractions, nerve treatment, spacer appliances, sealants and other such dental treatments after a detailed treatment plan is presented for proper informed consent.
I fully understand there is a possibility of surgical and /or medical complications developing during or after the procedure. These risks and side effects may cause necessary hospitalization, further surgical procedures, disabilities, nerve damage, brain damage, or death. I further authorize the doctor to perform treatment as may be
advisable to preserve the health and life of my child.
I hereby state that I have read and understand this consent and that all questions about the procedure(s) have been answered in a satisfactory manner. I understand that I have a right to be provided with answers to questions, which may arise during the course of my child’s treatment. This consent will remain in effect until such time that I choose to terminate it.