Patient Name

Age

Sex

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Female

Address

Medical History

Known Drug Allergy

Parent's Name

It is the policy of this dental practice 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 regular examination visit consists of oral hygiene instructions, cleaning of the teeth, topical
application of fluoride, radiographs (X-rays) if needed and examination of the teeth, hard and soft
tissues of the mouth and the bite.
• Any other treatment needed such as fillings, caps, extractions, etc. will be performed at a separate
appointment after obtaining your permission.
Indian Law requires that we obtain your written informed consent for any treatment given to your child as a
legal minor.


1. I hereby authorize and direct Dr. assisted by other dentists and/or dental
auxiliaries of his/her choice, to perform the following dental treatment or oral surgery procedures,
including the use of any necessary or advisable local anesthesia, radiographs (X-rays) or diagnostic
aids.
2. In general terms the dental procedures or operation will include:
o Cleaning of the teeth and the application of topical fluoride.
o Application of plastic “sealants” to the grooves of the teeth.
o Treatment of the diseased or injured teeth with dental restoration (filling or caps).
o Replacement of missing teeth with dental prosthesis.
o Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities
Use of local anesthesia, by injection, to numb the teeth worked on. Numbness usually lasts from 1 ½
to 3 hours. Allergic reactions are rare. Your child will be cautioned not to bite the numb lip and check.
Please do not tell your child that they are going to get a “shot” as we have our special way of
informing them about this.
4. Nitrous Oxide (laughing gas) is used to relax children so that they feel less pain of the injection.This
gas is placed over the child’s nose. Again, this gas is very safe. The nose piece, as with all treatment,
will not be forced onthe child.
I fully understand there is a possibility of surgical and/or medical complications developing during or after the
procedure.
I further authorize Dr Pranjal Bari to perform treatment to preserve the dental health of my child.
I further understand that parents must remain in the reception area for the duration of their child’s visit.
However, for the initial visit, that parent will accompany the child to the consultation area. Upon completion of
consultation, the parent will be requested to return to the reception area.
I hereby state that I have read and understand this consent form and that all questions about the procedures
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.
I further understand that this consent will remain in effect until such time that I choose to terminate it

Date

Time(AM/PM)

AM
PM

Patient's Name

Signature of Parent/Guardian

Relationship to Patient

Behaviour Management Techniques
Among the behaviours that can interfere with the proper provision of quality dental care are: Hyperactivity,
resistive movements, refusing to open the mouth or keep it open long enough to perform the necessary dental
treatment and even aggressive or physical resistance to treatment, such as kicking, screaming and grabbing the
dentist’s hands or the sharp dental instruments.
All efforts will be made to obtain the cooperation of the child dental patients by the use of warmth, friendliness,
persuasion, humour, charm, gentleness, kindness and understanding. There are several behaviour
management techniques that are used by paediatric dentists to gain the cooperation of child - patients to
eliminate disruptive behaviour or prevent them from causing injury to themselves due to uncontrollable
movements. The more frequently used paediatric dentistry behaviour management techniques are as follows:
Tell-show-do: The dentist or assistant explains to the child what is to be done using simple terminology and
repetition and then shows the child what is to be done by demonstrating with instruments on a model or the
child’s or dentist’s finger. Then the procedure is performed in the child’s mouth as described. Praise is used to
reinforce cooperative behaviour.
• Positive reinforcement: This technique rewards the child who displays any behaviour which is
desirable. Rewards include compliments.
Voice control: The attention of a disruptive child is gained by changing the tone or increasing the
volume of the dentist’s voice. Content of the conversation is less important than the abrupt or sudden
nature of a command.
• Mouth props: A rubber or plastic device is placed in the child’s mouth to prevent closing when a child
refuses or has difficulty maintaining an open mouth.
• Sedations: Sometimes drugs are used to relax a child who does not respond to other behaviour
management techniques or who is unable to comprehend or cooperate for the dental procedures.
These drugs may be administered orally, by injection or as a gas (nitrous oxide and oxygen).Your
child will not be sedated without you being informed and obtaining your specific consent for such
procedure.
• General anesthesia: The dentist performs the dental treatment with the child anesthetized in the
hospital operating room. Your child will not be given general anesthesia without you being informed
and obtaining your specific consent for such procedure.

Parent's Signature

Date