Dental Consent Form

DENTAL CONSENT FORM

Patient Information

Date of Birth:    Phone:    Email:

Medical History

 Pregnant or attempting pregnancy      Cardiac pacemaker or implantable device      History of bleeding disorder

WHEREAS (Recitals)

WHEREAS, Patient Name: (the "Patient") seeks dental evaluation and/or treatment; and

WHEREAS, Dental Practice Name: (the "Provider") is duly licensed and qualified to perform dental services; and

WHEREAS, the parties desire to set forth the terms under which Provider will perform dental procedures and Patient will consent and authorize such services as described herein.

Scope of Work

The Provider will perform the dental procedures described below. The Patient acknowledges that the Scope of Work may include examination, diagnostics, radiographs, restorative procedures, extractions, periodontal therapy, anesthetic administration, and other customary dental treatment as needed.

Payment Terms

The Patient agrees to pay for services rendered in accordance with the Provider's fees and this Payment Terms section. Estimates are provided in good faith but are not guarantees of final cost.

Late Payment: will be applied to overdue balances after days. Patient is responsible for all collection costs and reasonable attorney fees related to nonpayment.

Term and Termination

This Consent and Treatment Agreement is effective as of the date signed and continues until the described treatment is completed or until terminated as set forth below.

Treatment Start Date:    Anticipated Completion Date:

Either party may terminate this agreement upon written notice. If the Patient cancels without providing at least days' notice, the Provider may assess a cancellation fee consistent with Provider policy.

Confidentiality and Privacy

Provider will maintain the confidentiality of Patient health information in accordance with applicable law. Patient authorizes Provider to use and disclose protected health information for treatment, payment, and healthcare operations. Patient may restrict disclosure by written request; Provider will comply to the extent required by law.

Patient authorizes the release of dental and medical information to the insurance company named above for the purpose of claims and payment processing:   I authorize

Consent, Risks, and Acknowledgement

I acknowledge that Provider has explained the nature, purpose, expected benefits, and material risks associated with the proposed treatment, including but not limited to infection, bleeding, nerve injury, tooth or root fracture, failure to resolve symptoms, the potential need for additional procedures, and allergic reactions. I understand that no guarantee has been made as to the results of treatment.

I consent to diagnostic procedures including radiographs and photographs when deemed necessary:   I consent

I consent to administration of local anesthesia, sedation, or other agents as required for the procedure(s):   I consent

By signing below, the Patient certifies that they have read and fully understand this Consent Form, that all questions have been answered to the Patient's satisfaction, and that the Patient freely consents to the procedures described above.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Entire Agreement

This Consent Form, together with any pre-treatment estimates and Provider policies expressly incorporated herein, constitutes the entire agreement between the Patient and the Provider with respect to the subject matter hereof and supersedes all prior negotiations and understandings, whether written or oral.

Sign Now