DENTAL TREATMENT CONSENT
I am the parent of the child named above. I give consent for my child to receive the dental screening/assessment and oral health services by an Affiliated Practice Dental Hygienist. To the best of my knowledge, the medical history questions have been answered accurately. I allow my child to receive x-‐rays, cleaning, sealants and/or fluoride treatment that may be recommended. The services provided are subject to change depending on numerous factors, including the patient’s behavior, the amount of future work needed and time.
• Preventative/Diagnostic procedures: x-‐rays, prophylaxis (cleaning), fluoride treatment and sealants when necessary (these services will be billed to insurance)
• Visual Exam
I understand that the Affiliated Practice Dental Hygienist providing the care is an Arizona licensed dental hygienist and that this care does not take place of a complete examination or dental care. I understand that the hygienist will refer my child to a dentist for treatment outside the hygienist’s scope of practice, and that if my child has not received treatment, the dental hygienist may not provide further treatment.