First Name: *
Last Name: *
Your child has recently been examined at Hi 5 Dental by Dr. Pham or an associate, and is in need of dental care. We look forward to caring for your child and this form will explain any possible care that your child may need, and requests permission to provide that care. If this form is not signed, your child will receive NO dental care other than emergency care to relieve immediate pain.
The teeth to be treated will be listed on the formal treatment plan form. Decay dissolves the tooth and, if not treated, will result in an abscessed tooth causing pain and infection. Teeth with early cavities will be identified and may be watched to determine if decay will progress. The dentist will remove the decayed and weakened part of the tooth and replace it with silver or tooth colored restoration to replace tooth structure.
If decay is very deep the dentist may recommend a protective barrier called an "indirect pulp cap" be placed over the deep portion. If the decay extends into the nerve of the tooth, see definition of nerve or pulp treatment below. Sedative fillings may be placed as an interim restoration if a permanent restoration is unable to be placed for a variety of reasons. Local anesthetic will be used to "numb" the area being treated. The numb feeling will last for one or two hours after treatment. New decay can form around fillings and may be necessary, over time, to replace fillings if new decay develops.
Back teeth may have deep grooves and pits where decay is more likely to start. The grooves will be sealed with a composite filling material to prevent the decay from starting. In order to provide ideal placement conditions, anesthetic and the use of a rubber dam may be required. Sometimes decay may be discovered during the sealing process and you will be notified that a filling is required. Sealants are not permanent and may need replacements after their normal lifespan has expired. Sealants have the potential to leak and cavities can form. It is important to have regular check-ups to evaluate sealants.
If a tooth has been badly broken down by decay, a filling will not stay in place. Therefore, a tooth is trimmed on the top and sides to allow a preformed "cap" to be placed over the tooth and protect it from breaking. As with fillings, anesthetic will be used.
When the decay or infection progresses far enough that the tissue inside the tooth has been infected, all or part of that infected tissue must be removed and a special filling will be placed in order to prevent the infection from spreading. Pulp treatment is not 100% successful and may require re-treatment or extraction if the infection doesn't resolve. This treatment requires the use of anesthetic. After treatment, a filling or a stainless steel crown will need to be placed. Pain or swelling after treatment is rare and usually minor.
If the infection has spread too far to rebuild the tooth, it is often best to remove the tooth to prevent the infection from spreading. After "numbing" the area with local anesthetic, the tooth is removed and the area is packed with gauze to control bleeding. Post operative instructions will be provided for care after the extractions. Risks of extraction can include post-operative pain, bleeding, and infection. Some teeth may not come out in one piece. Sometimes it is necessary to refer to an oral surgeon, in the event the pieces cannot be removed.
If your child is particularly nervous about dental treatment, the dentist may use "happy air" to help relax your child. Nitrous oxide is a very safe and effective sedative. Nitrous oxide may cause nausea, but its frequency is quite low. Please advise the doctor and staff if your child has a cold, upper respiratory infection, asthma, or difficulty breathing. Nitrous oxide is one aid in behavior management; we can not guarantee that its use will allow for in-office treatment of your child's dental needs.
An appliance made of metal that saves space for the permanent teeth to erupt following early removal of baby teeth.
I hereby acknowledge that I have read and understand this consent form; that I have been given an opportunity to ask questions that I may have; and that all questions about treatment alternatives and risks have been answered in a satisfactory manner. I further understand that I have the right to be provided with answers to questions which may arise during the course of my child's treatment. I further understand that I am free to withdraw my consent to treatment at any time and this consent shall remain in effect until I choose to terminate it.
First Name *
Last Name *
Date (MMDDYYYY) *
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I authorize the following to perform these procedures
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| Meet The Doctors
| Dentistry for Kids
| Office Info
| New Patients
| Referring Doctors
| Hai Pham, DMD
| Jenette Intrachat, DDS
| Grace Shao-Chiu Chen, DMD, MS
| Jessica Irwin, DMD
| Dental FAQ
| First Visit
| Preventive Care
| Treating Decay
| Early Orthodontics
| Sports & Mouthguards
| Special Needs
| Sedation Dentistry
| Dental Emergencies
| Hi5 Dental in Hillsboro
| Hi5 Dental in Cedar Hills