DENTAL TREATMENT CONSENT FORM - Camino Health Center - caminohealthcenter 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. In the 'WORK TO BE DONE' section, check off the procedures that will be performed and fill in any additional treatments as necessary.
4. Initial next to each statement in the 'DRUGS AND MEDICATIONS' section to acknowledge your understanding of potential allergic reactions.
5. Review and initial the 'CHANGES IN TREATMENT PLAN' section, granting permission for any necessary adjustments during treatment.
6. In the 'REMOVAL OF TEETH' section, specify which teeth may need removal and initial after reading about potential risks involved.
7. For 'ENDODONTIC TREATMENT', initial to confirm your understanding of possible complications related to root canal procedures.
8. If applicable, authorize nitrous oxide administration by initialing in that section.
9. Finally, review all information provided, sign at the bottom as a parent/guardian, and date your consent.

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