1.    Treatment to be Provided
    I understand that during my course of treatment that the following care may be provided:
    Clinical Examinations, Preventative, Treatment, Restorations, Crowns, Bridges,

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

    3.   Changes in Treatment Plan
     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 and reasonable.

    4.   Data Collection
    I understand that the data collected will only be used for my dental care and will not be shared without my consent.

    5.   Contact
    I consent to receiving telephone calls, text messages or emails regarding my dental care.


    Parent/Guardian Signature