CONSENT FOR DENTAL TREATMENT
I request and authorize Dr. Lisa Ameer and her staff to perform cleanings, exams and place topical fluoride treatments on my child. I request and authorize dental x-rays to be taken on my child as considered necessary by Dr. Lisa Ameer to diagnose and/or treat my child’s dental needs. I acknowledge that I have been explained all the behavior management techniques that may be used with my child while experiencing dental treatment. I have been given the opportunity to discuss any questions that I may have.
I am permitted by law (by right as a natural parent, legal adoption, or court order) to provide consent for the dental treatment of this child.(Documentation may be requested from you regarding rights ofparental consent for the child)