Informed consent for sealants

An informed consent form for dental sealants. The patient acknowledges that the dentist recommended sealants on specific teeth after an exam, and that their purpose is to lower the risk of cavities on the chewing surfaces. It lists risks, such as the etching solution touching soft tissue and causing temporary discomfort, dust from surface abrasion, and loss or breakage of the sealant.

Have a parent or guardian sign it for children, or the patient for adults, before sealants are placed. The hygienist or assistant reviews the risks, fills in the tooth numbers, and saves the signed form to the chart.