INFORMED CONSENT FORM

Our pediatric dental office philosophy is based on our commitment to preventive dentistry and to creating a supportive and nurturing environment for the children and young adults under our dental care. 

 

We require informed consent before we can provide any dental services for your child.  Our most important general office policy is to inform before we perform.  Specifically, we are requesting your permission for the following diagnostic and preventive dental procedures: comprehensive clinical examination selected diagnostic x- rays, thorough professional cleaning, and decay- fighting fluoride treatment. 

 

If dental treatment is necessary, we require your consent for a number of additional procedures which include, but are not limited to the following: local anesthesia (lidocaine), comfortable mouth prop (“tooth pillow”) and extensive use of the classic ‘tell- show- do’ method of introducing new methods and materials to your child. 

 

I have read the above information and give my consent to North Shore Dentistry for Children to provide mutually agreed upon dental services for my child.  I am aware that the above-mentioned providers are specialists in pediatric dentistry.  I further agree that this consent shall remain in full force unless withdrawn in writing by the person who has signed below on behalf of the minor patient or themselves. 

 

Thank you for taking the time to read and sign this document. 

Parent/Guardian Signature

PHONE
(847) 869-5417
(847) 869-5509 FAX

LOCATION

One Rotary Center
1560 Sherman Avenue, Ste. 610
Evanston, Illinois 60201

HOURS

Mondays, Wednesdays & Thursdays:
7:30 AM — 5:00 PM
Tuesdays: 8:30 AM — 5:00 PM
Fridays: 7:30 AM — 2:00 PM

Saturdays : 8:30 AM — 3:00 PM

Copyright © 2020: All Rights Reserved: North Shore Dentistry for Children