Consent Form

Bridging Brighter Smiles, Inc. – SDF Consent Form

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

Consent for Silver Diamine Fluoride (SDF) Treatment

School District*
School Name*
Student Info - Please use Legal Name
Dependent*
First Middle Last
Date of Birth*
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
*
I understand that my child will have the following treatment performed. Silver Diamine Fluoride (SDF) to stop cavities from progressing. SDF is a liquid used on cavities to help stop tooth decay. In some cases, where a dentist would do a regular filling, it is now possible to use a less invasive treatment to stop the decay process. With this consent, up to 4 treatments may be provided on the teeth indicated, as determined by the Dental Hygienist. Every reasonable effort will be made to ensure the success of SDF treatment. There is a risk that the procedure will not stop the decay and no guarantee of success is granted or implied **Treatment with SDF does not eliminate the need for dental fillings or crowns to repair tooth function. Additional procedures will require a visit to your dental office.
Authorization
*
I understand that by signing this form, SDF treatment can and will be provided for my dependent. This consent will run concurrently with my dependent’s Bridging Brighter Smiles enrollment form. I have read and understand the side effects of SDF. I authorize BadgerCare/Medicaid insurance payments for services rendered to Bridging Brighter Smiles, Inc. and agree to pay any BadgerCare/Medicaid copays. If my dependent is not insured through BadgerCare/Medicaid insurance, I agree to pay the standard fees for services rendered.
Electronic Signature
I understand that by selecting "I agree" below, this constitutes a legal signature. I authorize BadgerCare/Medicaid insurance payments for services rendered to be forwarded to Bridging Brighter Smiles, Inc. I agree to pay any BadgerCare/Medicaid copays. If my dependent is not insured through BadgerCare/Medicaid insurance, I agree to pay the standard fees for services rendered (see Coverage Information) directly to Bridging Brighter Smiles, Inc.*
- I Agree
Parent/Guardian Electronic Signature*
Date*
Office Use Only

Bridging Brighter Smiles, Inc. – SDF Consent Form

Consent for Silver Diamine Fluoride (SDF) Treatment

Student Info - Please use Legal Name

Side Effects

Alternatives to SDF (not limited to the following)

Parent/Guardian Info

Authorization

Electronic Signature

Office Use Only