Bridging Brighter Smiles, Inc. – SDF Consent Form

Questions? Please Feel Free to Call (262) 896-9891

Consent for Silver Diamine Fluoride (SDF) Treatment

  • Student Info - Please use Legal Name

  • MM slash DD slash YYYY
  • Side Effects

    1. The area treated will change color to brown or black. This means the treatment is working and stopping the cavity. The dark stain is like a scar. Healthy tooth structure will not stain.
    2. If accidentally applied to skin or gums, a brown stain may appear that causes no harm, cannot be washed off, and will disappear in 1-3 days.
    3. A metallic taste may be noticed, this will go away rapidly.
    4. These side effects may not include every possible situation. If you notice other effects, please contact us at 262-896-9891.

  • Alternatives to SDF (not limited to the following)

    1. No treatment, which may lead to continued deterioration of tooth structures. Symptoms may increase in severity to include pain and ultimately tooth loss.
    2. Other treatment may include a filling, crown, extraction or other procedure as determined by a dentist.

  • Parent/Guardian Info

  • Authorization

  • Electronic Signature

  • Office Use Only

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