MINOR/CHILD DENTAL PROCEDURE CONSENT FORM

Patient Name ________________________________________________ DOB ____________________________ Date of Treatment __________________________

☐ WORK TO BE PERFORMED Initials______

I understand that my child is having the following work done:

☐ Exam ☐ X-Rays ☐ Cleaning ☐ Nitrous Oxide ☐ Local Anesthetic ☐ Fillings___________________________

☐ DRUGS AND MEDICATIONS Initials______

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

☐ CHANGES IN TREATMENT PLAN Initials______

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not

discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make

any/all changes and additions as necessary.

☐ SEALANTS Initials______

Back teeth have grooves and pts in which decay usually starts. The dentist or hygienist will “seal” the grooves with a plastic coating to help prevent the decay

from starting. No anesthetic is needed.

☐ EXTRACTIONS OR REMOVAL OF TEETH Initials______

If the infection has spread too far to build the tooth, it is often best to remove the tooth to prevent infection from spreading. After “numbing” the area with

anesthetics, the tooth is removed and the area packed with gauze to control bleeding. Care should be taken not to rinse for a couple of days or bleeding may begin again. Biting on gauze will usually stop the bleeding. Pain or swelling after this work is possible and usually minor.

☐ SPACE MAINTERNER Initials______

At times it is impossible to save a tooth. In such cases, the only alternative is to resort to extraction. Depending upon the necessity to maintain space for the

eruption of permanent teeth it may be necessary to insert appliances known as space maintainers. These space maintainers may be either fixed or removable.

☐ ENDODONTIC TREATMENT (PULPOTOMY) Initials______

Due to the thinness of the enamel, large pulp (nerve) chambers, and rapid spread of caries (decay) in the deciduous teeth, the dentist may drill into the pulp

chamber during decay removal. Upon such pulpal or nerve exposure, extraction may often be avoided by rendering a treatment in which the pulp tissue in the upper part of the tooth is removed and replaced with various filling materials and the tooth preserved to maintain space and chewing capability until the permanent

tooth replaces the deciduous tooth. This procedure is called Pulpotomy. At times, no matter how well done, these teeth may become infected and require

extraction.

☐ STAINLESS STEEL CROWNS Initials______

If a tooth is badly destroyed by decay, a filling will not stay in place. Therefore, a tooth is trimmed around the sides and a preformed crown or “cap” is placed over the tooth to protect it from breaking. Furthermore, anytime a Pulpotomy is performed, a stainless steel crown will need to be placed. As with fillings, the area is

usually treated with an anesthetic to help the child remain comfortable for one to two hours.

☐ JUVENILE PERIODONTITIS (TISSUE BONE LOSS) Initials______

I understand that I have a serious condition, causing gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse

effect on my periodontal condition.

☐ ABCESSES Initials______ Deciduous teeth are particularly susceptible to a condition known as abscessing. Abscesses can occur if there has been deep invasion of caries into the tooth

causing pulp tissue to become infected. The tooth usually becomes very sore and/or painful and swelling appears in the tissue near the root of the tooth. Abscesses

may also occur from a traumatic injury to the tooth. The office should be contacted immediately if this occurs. Pulpotomy as described above is generally not performed on abscessed tooth. And other alternatives must be considered.

A complete consultation has been provided and have been given the opportunity to ask any questions concerning the dental treatment of my child. All questions have

been answered to my satisfaction. I do voluntarily assume any and all possible risks, including but not limited to those addressed above, including the risk of substantial

harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired potential results, which may or may not be achieved. No promises or guarantees have been made concerning the results. The fee(s) for this service have been explained to me and are satisfactory.

Signature of Parent/Guardian If patient is a minor ______________________________ Date______________________________

Behavior Management Consent Form Please read this form carefully. If you do not understand something to your satisfaction, please ask us, we will be pleased to explain it to you. 1. I request and authorize the dental treatment by Dr. Niloo Khalesseh and staff.

Patient Name: _____________________________________________________DOB _________________________

Patient Name: _____________________________________________________DOB _________________________

Patient Name: _____________________________________________________DOB _________________________

Patient Name: _____________________________________________________DOB _________________________

2. I, ________________________________, am the legal guardian of the child named above. _________ (Initials) 3. I further request and authorize the taking of dental x-rays and the use of anesthetics as may be considered necessary to treat my child’s

dental need(s). 4. I have had explained to me by Dr. Niloo Khalesseh and staff, and have had sufficient opportunity to discuss the patient’s dental

condition/problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment plan, compared with alternative approaches and/or no treatment.

5. It is unusual for any of the following risks or complications to occur. These risks or complications include but are not limited to, the

possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions.

6. I understand that during the course of the patient’s dental treatment, something unexpected may arise that may necessitate procedures

in addition to or different from those listed on the patient’s treatment plan and that I will be consulted prior to initiation of treatment procedures not listed. I am aware that the practice of dentistry is not an exact science, and there is a possibility of treatment failure based on the patient’s reaction to the treatment. I acknowledge that no guarantees have been made to me concerning the results of the dental treatment that the patient receives in this office.

7. I understand that behavior management is key to a productive and successful treatment. We may use kind words of affirmation,

explanation, and demonstration of procedures and instruments, using variable voice tones, to help patients understand the treatment in terms appropriate for their age.

8. I understand that should the patient become uncooperative during dental procedures with movement of the head, arms and/or legs,

dental treatment cannot be safely provided. I understand that in situations like this the only way I can guarantee my child will not cry or be unhappy during dental treatment is if I elect to have their treatment completed in the operating room under general anesthesia. I also know conscious sedation is an option for some children, and Dr. Niloo Khalesseh will discuss all the alternatives with me.

9. I understand that it is not an uncommon response for children to cry during dental treatment or directly afterward. 10. All of my questions have been answered to my satisfaction and I consent to the treatment and procedures prescribed for the patient on

the treatment plan. 11. I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated

except to the extent that treatment and procedures have already been performed or initiated. 12. I confirm that I am a legal guardian to the child aforementioned. I also confirm that I have read and understand this form or it was read

to me, and that all blanks were filled in and all inapplicable paragraphs, if any, were stricken before I signed below.

Signature and name of Person Consenting to Treatment Date

HIPPA NOTICE OF PRIVACY PRACTICES

Federal protection for the privacy of health information and personal information is in effect.

The HIPAA Notice of Privacy Practices for this dental office is available at the front desk when

requested. Your signature below indicates that you are acknowledging notification of the

privacy practices of this office.

Acknowledgement of Privacy Rules: ___________________________ Date: _______________

ARBITRATION AGREEMENT

This dental practice agrees to provide to the undersigned patient dental health care services in

consideration for the payment received. By signing this arbitration clause you are agreeing to

have any issue of dental malpractice decided by neutral arbitration and you are giving up your

right to a jury or court trial. The arbitration agreement you are accepting is available at the front

desk when requested.

I have read the material available at the front desk.

I would like to request a printed copy to take with me.

Acknowledgement of Arbitration Agreement: _____________________ Date: ______________

CHILD OR MINOR SOCIAL MEDIA AUTHORIZATION

At Fusion, we strive to create a family environment for our patients. We regularly interact with

our patients and community through social media. We need your written consent if you would

like us to include your child or children in our cool online updates.

You may use my child’s first name & photo on your Web site gallery and social media

pages. This may include Facebook, Google+, Twitter, Instagram, and Pinterest.

You may use my child’s photo as referenced above, but no name.

I would prefer that my child’s smile is not featured online.

Parent or Legal Guardian: _____________________________________ Date: ______________

FINANCIAL AGREEMENT This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our experienced office staff. DENTAL INSURANCE PATIENTS:

• You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim.

• Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you and not your insurance company.

• You are responsible for our fees and not what your insurance company allows or considers "usual, customary and reasonable" all of which vary from one company to another.

• Although we may estimate your insurance benefits we are not responsible for their accuracy. Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate.

• All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for non-covered services, along with deductibles and copayments are due at the time of treatment.

PATIENTS WITHOUT INSURANCE COVERAGE: We provide written estimate of fees, and payment is expected at each visit for services rendered.

PAYMENT POLICY

• We accept cash, personal checks, debit cards, Care Credit, and major credit cards. • If your insurance has not paid or denied your claim within 45 days, it will be your

responsibility to pay the full balance of all unpaid claims.

RETURNED CHECKS: A $50.00 charge applies when the bank returns a check.

THIRD PARTY FINANCING: If a third party is used to finance dental treatment (e.g. Care Credit, Citi Health), you have 15 calendar days to cancel your treatment and receive a full refund. Cancellation requests received after 15 calendar days are subject to a 15% fee on the amount financed.

Cancellation requests received after treatment has begun will be refunded in full minus the fee/price of the services rendered, provided they are within 15 calendar days.

Cancellation requests received after 15 calendar days and after treatment has begun will be processed in the amount financed minus 15% penalty fee, minus the fee/price of the services rendered.

Initials ______

PAST DUE BALANCE: An account with an unpaid balance past 60 days will be sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt from the last date of service, such as attorney fees, court fees and any other fees associated with the collection of your debt. FINANCE CHARGES AND COLLECTION FEES: Finance charges will be applied to all balances not paid within 60 days of the billing date. A late charge of 1.5% on the balance unpaid and owed will be assessed each month until paid.      BROKEN OR MISSED APPOINTMENTS: To reschedule or cancel an appointment, you must notify us at lease twenty-four (24) hours in advance to avoid a missed appointment fee of $50. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept.

DENTAL RECORDS: Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs for a nominal duplication fee of $10.

CONSENT & AUTHORIZATION: I authorize dental treatment on my self/child and agree to pay all related professional fees. Fees not covered or paid by my dental insurance will be promptly paid upon notification from this office. I have read and understood this document in its entirety, outlining office policies and financial policies of Fusion Children’s Dentistry & Orthodontics. Without any reservations, I agree to abide by the policies outlined herein.

Name: _______________________ Signature: ____________________ Date: ________________