DENTAL HISTORY

First
MI
Last

Any Oral Habits? Yes/No

Please indicate if you child has issues with any of the following?

Consent for Dental Treatment

I authorize the rendering of diagnostic and treatment procedures including, but not limited to: fluoride, local anesthesia, and radiographs. I authorize the doctors and dental staff of Prime Pediatric Dentistry to provide services, that in their professional opinion, may be deemed necessary or beneficial. However, prior to rendering any definitive treatment, the proposed treatment plan will be presented and/or discussed with the parent or guardian.

I further understand that this consent will remain in effect until such time that I effectively choose to terminate consent for dental treatment.