This information is being provided so you may make an informed decision concerning the proposed dental treatment for your child. If you have any questions about the technique, benefits, and risks of protective stabilization (or any aspect of the treatment plan) after we review this information, please ask and obtain acceptable answers before signing this document.

Dental treatment with protective stabilization is being suggested to help keep your child safe during dental treatment and allow us to provide quality care. The risks of protective stabilization may include, but not limited to, the following; bruising of the hands and legs if the child continues to resist treatment and irritation of skin.

I have read and understand this form, and had ample opportunity to discuss the use of protective stabilization, the risks/benefits/and alternatives available. All my questions have been answered and I realize I can always seek further information.

I give consent for the patient listed above to receive dental treatment using protective stabilization.