Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential.

  • (*) indicates a required field.
  • State law requires us to obtain your written consent for dental treatment or surgery. Please read this form carefully and ask about anything that you do not understand. We will be pleased to explain it.

    1. I herby authorize Dr. Griffith, assisted by other dentists, and / or dental auxiliaries of their choice to perform upon my child or legal ward dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays) or diagnostic aids.

    2. In general terms the dental procedure(s) or operation may include:
  • A. Examination, cleaning of the teeth and application of topical flouride
    B. Use of physical restraint or restraining devices to safely accomplish the necessary dental procedures.
  • C. Application of plastic "sealants" to the grooves of the teeth.
    D. Treatment of diseased (decayed) or injured teeth with dental restorations (fillings or crowns).
    E. Treatment of diseased or injured oral tissues (hard and/or soft), including nerve treatment(s).
    F. Removal (extraction) of one or more teeth.
  • G. Replacement of missing teeth with dental prosthesis.
    H. Treatment of malposed (crooked) teeth and / oral development or growth abnormalities.
  • I. Use of sedative drugs to control pain, gagging, apprehension and/or disruptive behavior.
    J. Use of general anesthesia to accomplish the necessary treatment. K. Nitrous oxide gas for pain control.
  • For Office Use Only:

    Signature of Dentist/Staff:



    Date: