Form

CONSENT FOR DENTAL TREATMENT

I understand that the information (e.g. health history, insurance information, etc.) I have given is correct to the best of my knowledge and that it will be held in strict confidence by Children’s Dental Centre. It is my responsibility to inform this office of any changes in my child’s medical and insurance status.

I request and authorize Dr. Kaitlin J Hoogeveen to examine, clean and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental radiographs (x-rays) considered necessary by Dr. Kaitlin J Hoogeveen to diagnose and/or treat my child’s dental problem(s). I will allow photographs to be taken of my child and/or child’s teeth for diagnostic or educational purposes.

I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Kaitlin J Hoogeveen will provide an environment likely to help children/individuals learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone to direct the patient’s behavior.

I have read and agree to the "Consent for Dental Treatment" as written above

I acknowledge I have read, understand, and agree to Children’s Dental Centre’s Consent to Dental Treatment as listed above, effective for the children/individuals listed below:

Patient's First Name

Last Name

Date Of Birth

Patient's First Name

Last Name

Date Of Birth

Patient's First Name

Last Name

Date Of Birth

Patient's First Name

Last Name

Date Of Birth

Patient's First Name

Last Name

Date Of Birth

Parent's First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date

CONSENT TO DENTAL CARE FOR A MINOR

(when a parent or legal guardian cannot be present)

I cannot accompany my child/children listed above to their scheduled appointment. I hereby give consent for the accompanying adult listed below to act as legal guardian during this appointment. (Please note the dental provider will reach out to the phone number on file to discuss any significant changes to the agreed upon dental treatment plan.) I also agree and give the Children's Dental Centre consent to discuss health information with the listed accompanying adult. By signing below you are acknowledging you have read, understand, and agree to the Consent to Dental Care for a Minor.

Accompanying Adult

Parent's/Legal Guardian Name

Last Name

Date Of Birth

Parent/Legal Guardian Signature

Date