(State law requires us to obtain your consent for contemplated dental treatment or oral surgery. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain it.)

I understand that the information that I have given is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my Child‛s medical status. Your child is a minor; therefore it is necessary that a signed permission be obtained from a parent or guardian before necessary dental services can be started. I authorize, request, and permit Dr. Thames and any employees/staff under his direct supervision to provide any dental/medical treatment necessary in connection with my child. This includes the use of any necessary or advisable local anesthesia, radiographs (x-rays) or diagnostic aids.

General terms dental treatment may include:

Cleaning of the teeth and application of topical fluoride
Application of plastic “sealants” to the groves of the teeth
Treatment of diseased or injured teeth with dental restorations (fillings or crowns)
Removal (extractions) of one or more teeth
Treatment of malposed ‘crooked‛ teeth and/or oral development of growth abnormalities
Use of sedative nitrous oxide/oxygen if needed to assist in a more pleasant dental treatment.