Healthcare Contract for Extraction

HEALTHCARE CONTRACT FOR EXTRACTION

This Healthcare Contract for Extraction (the "Agreement") is entered into by and between:

Patient Name:    Date of Birth:

Provider Name:    Provider License/Tax ID:

Patient Information

Male Female Other Prefer not to say

Insurance Information

Medical History

Bleeding disorders or anticoagulant therapy: Yes No

Are you pregnant or trying to become pregnant? Yes No

Procedure Description and Authorization

Description of proposed extraction:

I hereby authorize the Provider and designated clinical staff to perform the extraction described above, including necessary adjunctive procedures (e.g., alveoloplasty, suturing). I acknowledge that no guarantee of outcome has been made.

Anesthesia / Sedation

Anesthesia(s) proposed (check all that apply):

Local anesthesia Nitrous oxide (laughing gas) IV sedation / conscious sedation General anesthesia

I consent to the administration of the selected anesthesia by qualified personnel. I understand that anesthesia involves risks, including but not limited to allergic reaction, respiratory depression, cardiac events, and in rare cases death.

Risks, Benefits, and Alternatives

The risks of extraction include, but are not limited to: persistent bleeding, infection, dry socket, delayed healing, damage to adjacent teeth or restorations, nerve injury resulting in numbness or altered sensation, sinus communication, scarring, need for additional procedures, and in rare circumstances, serious systemic complications. Benefits and expected outcomes have been explained to me.

Reasonable alternatives to extraction, including conservative therapy, endodontic treatment, or no treatment, have been explained. I have had the opportunity to ask questions and all questions have been answered to my satisfaction.

Patient acknowledges receipt of risk/benefit explanation: I acknowledge

Financial Agreement

The patient or responsible party agrees to be financially responsible for all fees associated with the extraction procedure, including professional, facility, anesthesia, and ancillary charges not paid by insurance.

Cancellation and no-show policy have been explained; fees may apply for late cancellation or missed appointments. I agree to pay any balances due after insurance adjudication.

Payment method:

HIPAA / Privacy & Release

I acknowledge that I have been offered the Provider's Notice of Privacy Practices. I authorize the Provider to use and disclose my protected health information for treatment, payment, and healthcare operations as necessary to provide care and process claims.

I authorize the release of medical or dental records related to this extraction to insurers, referring providers, or other treating clinicians as necessary for continuity of care and payment.

Revocation and Withdrawal

I understand that I may revoke this authorization in writing at any time, except where action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made.

Acknowledgements and Certification

By signing below I certify that I have read and understand this Agreement, that the nature and purpose of the extraction and potential risks and benefits have been explained to me, and that my questions have been answered. I consent to the performance of the extraction and associated care by the Provider and their staff.

Patient certifies: I certify that the information provided is true and accurate to the best of my knowledge.

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