Silver Diamine Fluoride Informed Consent Leeward Pediatric Dentistry Patient Name* First Last Treatment & Tooth Number(s):* NA* 1) Silver diamine fluoride or ‘SDF’ offers treatment for patients who can’t tolerate injections or the dental drill 2) This is an antimicrobial liquid that stops decay - it outperforms other anti-caries medicaments in killing bacteria 3) SDF relieves sensitivity 4) SDF prevents further problems while the patient is waiting for definitive care 5) SDF can prevent future toothaches/infection 6) There will most likely be a change in color of the dentin as the decay arrests (most likely tooth decay will become black in color) 7) There is a likelihood of reapplication – one or two reapplications may be administered at intervals of one week 8) SDF can stain skin and clothes By signing this document in the space provided, I indicate that I have read and understand the information mentioned above and that I give my permission for Silver Diamine Fluoride treatment to be administered on my child. NA*1) Silver diamine fluoride or ‘SDF’ offers treatment for patients who can’t tolerate injections or the dental drill 2) This is an antimicrobial liquid that stops decay - it outperforms other anti-caries medicaments in killing bacteria 3) SDF relieves sensitivity 4) SDF prevents further problems while the patient is waiting for definitive care 5) SDF can prevent future toothaches/infection 6) There will most likely be a change in color of the dentin as the decay arrests (most likely tooth decay will become black in color) 7) There is a likelihood of reapplication – one or two reapplications may be administered at intervals of one week 8) SDF can stain skin and clothes By signing this document in the space provided, I indicate that I have read and understand the information mentioned above and that I give my permission for Silver Diamine Fluoride treatment to be administered on my child. I agree to the above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/01/2025HiddenId Form id. Input filed as a parameterHiddenUsername HiddenOffice Name HiddenEmail HiddenAdditional Email HiddenTitle HiddenShow Tooth Selection? HiddenNotes Title HiddenConsent Label HiddenCheckbox Label HiddenConsent Text 1) Silver diamine fluoride or ‘SDF’ offers treatment for patients who can’t tolerate injections or the dental drill 2) This is an antimicrobial liquid that stops decay - it outperforms other anti-caries medicaments in killing bacteria 3) SDF relieves sensitivity 4) SDF prevents further problems while the patient is waiting for definitive care 5) SDF can prevent future toothaches/infection 6) There will most likely be a change in color of the dentin as the decay arrests (most likely tooth decay will become black in color) 7) There is a likelihood of reapplication – one or two reapplications may be administered at intervals of one week 8) SDF can stain skin and clothes By signing this document in the space provided, I indicate that I have read and understand the information mentioned above and that I give my permission for Silver Diamine Fluoride treatment to be administered on my child.