I understand that by signing below I am requesting and authorizing the procedure(s) to be performed on my child and I have read and understand the possible risks and complications of the procedure(s). The doctor has reviewed all the treatment options with me and all my questions have been answered.

I understand that there are two options for my child’s crown: silver or white. As an alternative to the covered services of a stainless steel or silver crown, my dentist has offered to place an all porcelain crown. I understand that if I choose a cosmetic upgrade my insurance may not cover the cost of the procedure.

I understand that treatment results can vary. The above images are examples only and are meant to show the difference in appearance between silver and white crowns. I understand that treatment of my child’s teeth for which I desire cosmetic dental procedures to be performed may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected.

I understand that there has been no guarantee or assurance made by anyone in regard to the dental treatment I have authorized. I also acknowledge that I am ultimately responsible for all dental fee payments regardless of any dental insurance coverage.

I authorize Dr. Hatch to treat with SILVER CROWNS

I authorize Dr. Hatch to treat with WHITE CROWNS