Informed Consent for SDF Please complete this Consent for SDF Therapy form below. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header and no captcha (change), 2020-06-04 v1.2 : DOB changed to date dropdowns (change) Patient name:* First Last Patient date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Consent for SDFThe use of silver diamine fluoride in dentistry has been well documented for its safe and successful ability to control tooth decay and sensitivity. Its application is a conservative approach for the treatment of active decay. The Procedure: Dry teeth Application of 38% Silver Diamine Fluoride (FDA approved product) to appropriate teeth with visible cavities in very small amounts using a micro brush. Application of 5% Sodium Fluoride varnish (FDA approved product) used to seal Silver Diamine Fluoride into the treated tooth and to arrest the decay in the tooth. Home Fluoride Therapy Contraindications: Silver Diamine Fluoride Allergy (very rare) Possible Side Effects: A cavity in the presence of Silver Diamine Fluoride will turn that part of the tooth dark. This is an indication that the decay in the tooth is arresting. Stained tooth structure can be replaced with a restoration (fillings or crowns) If Silver Diamine Fluoride comes in contact with skin and/or gums, temporary discoloration will occur. If Silver Diamine Fluoride is placed on a tooth that has a tooth colored restoration on it, discoloration may occur. Silver Diamine Fluoride placed on demineralized enamel (white lesions) may cause discoloration. The side effects listed above may not include all of the side effects reported by the drug's manufacturer. If you notice other effects not listed above, please contact us. Treatment of tooth decay with Silver Diamine Fluoride does not necessarily prevent the need to place a regular filling in the affected tooth in the future in order to restore function and esthetics. ** Do not eat for one hour and do not brush your teeth for 24 hours after treatment. The above treatment technique has been explained to me to my satisfaction and I understand it fully. I have read this form, understand the treatment, have had the risks, benefits, and alternative treatments explained, and have had the chance to ask questions. I understand that I may refuse treatment. I give my consent to have Michael D. Vaughan, D.D.S., PLC administer Silver Diamine Fluoride. SubmitName of Legal Guardian or Authorized Representative:* If not applicable use 'self'Today's date:* MM slash DD slash YYYY Do you wish to receive a copy of this Consent?* Yes No E-mail address:* Please sign*Important: You consent to sign this document electronically.