Pediatric Dental Consent

About this form

The pediatric dental consent is a consent forms document used by dental practices. Parent/guardian consent for pediatric dental treatment and behavior management. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 9 fields:

• Child's Full Name — Text
• Child's Date of Birth — Date
• Parent/Guardian Name — Text
• Relationship to Child — Text
• I consent to dental examination and treatment for my child — Multiple choice
• I authorize behavior management techniques as needed — Multiple choice
• I will inform the office of any changes in my child's health — Multiple choice
• Parent/Guardian Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the treatment workflow, completing it with the patient after the procedure and its alternatives have been discussed. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.