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.

    I hereby authorize Dr. Chen, assisted by other dentist(s), 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.
  • I understand that although good results are expected, the possibility and nature of complications cannot be accurately anticipated and; therefore, no guarantee is expressed or implied either as the result of the treatment or as a cure. I further authorize the doctor to perform other dental service(s) that in her judgement are advisable for my child or legal ward. Although their occurrence is extremely rare, some risks have been reported to be associated with dental or oral surgery procedures. State law requires us to mention the possible risk of numbness, infection, swelling, bleeding, bruising, discoloration, nausea, vomiting, allergic or drug reactions, brain damage, stroke, heart attack, aspiration or swallowing of a foreign object, or scars associated with such procedures. I further understand and accept that complications may require hospitalization and may even result in death.

    I hereby state that I have read and understand this consent, and that all questions I have were answered to my satisfaction. I understand I have the right to be provided with answers to questions which may arise during the course of my child's treatment.

    I understand that this consent will remain in effect until such time that I choose to terminate it in writing.