I, the undersigned, as the parent or legal guardian of the child named above, provide my informed consent for the dental treatment of the child by the CDPPM’s dentists under general anesthesia. I understand that this treatment is necessary for my child's dental health and that there are associated risks and benefits.

List of dental treatments:

• Dental exam
• Dental radiographs
• Dental cleaning
• White fillings for front teeth
• Silver or white fillings for posterior teeth
• Pulp treatments
• Stainless steel crown
• Frenectomy
• Extractions
• Space maintainer

Risks and Complications:
According to the Canadian Anesthesiologists’ Society, adverse effects and serious complications are very rare, but the possibility does exist. The risk will vary according to your health beforehand and the seriousness of your operation. In Canada, the chance of a healthy person dying as a result of anesthesia is probably between 1 in 200,000 and 1 in 400,000. This is certainly comparable with the risks of commercial airline travel and much safer than travelling by car.

Benefits of Treatment:

1. Patient Comfort: For patients who are anxious or phobic about receiving dental care, general anesthesia keeps them unconscious during the procedure, reducing their anxiety and stress.
2. Complete Treatment in One Session: In cases of complex dental treatments that require multiple procedures, general anesthesia allows everything to be done in a single session, reducing the number of required visits.
3. Treatment of Young Children: Toddlers or children with special needs may have difficulty cooperating during dental treatments. General anesthesia can make treatment safer and more efficient for these patients.
4. Pain Reduction: General anesthesia keeps the patient unconscious during the procedure, eliminating the sensation of pain associated with many invasive dental treatments.

Alternatives:
Depending on the patient's cooperation, it may be possible to proceed with or without nitrous oxide (laughing gas) while in the dental chair. However, it will not be possible to complete all dental treatments in a single session.

Services not covered by RAMQ:

• 10 years old and beyond without a valid financial assistance program with claim slip
• Dental cleaning
• Sealants
• White fillings on posterior teeth
• Space maintainer

Authorization