Healthcare Dental Consent Form

DENTAL TREATMENT CONSENT FORM

Patient Information

Date of Birth:     Gender:

Dental Provider / Appointment

Appointment Date:     Tooth/Area:

Insurance Information

Medical and Dental History

Chronic Conditions (check all that apply):

Diabetes   Heart disease   High blood pressure   Bleeding disorder

Respiratory disease   Cancer   Immunosuppression   Other

Are you pregnant?   Yes   No

Planned Procedure and Anesthesia

Anesthesia / Sedation to be used:
Local anesthetic   Nitrous oxide (laughing gas)   IV sedation   General anesthesia   None

Risks, Benefits, and Alternatives

I understand that dental treatment has known risks and benefits. Common and less common risks include, but are not limited to: persistent pain or sensitivity; infection; swelling and bruising; bleeding; damage to adjacent teeth or restorations; temporary or permanent numbness, tingling, or altered sensation of the lips, tongue, chin or face; sinus involvement; difficulty opening the mouth; need for additional or alternative treatment; and anesthetic complications. Risks of sedation or general anesthesia may include respiratory depression, allergic reaction, cardiovascular events, or other systemic complications.

Benefits of the proposed treatment include resolution or improvement of the dental condition, relief of pain, restoration of function, and prevention of further disease. Alternative options include no treatment, different restorative or surgical approaches, or referral for specialty care. I have been informed of reasonable alternatives and the potential consequences of refusing treatment.

Acknowledgments and Consent

By signing below I certify that I have read and/or had explained to me the nature of the proposed procedure, the expected benefits, the material risks, and the available alternatives including no treatment. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I acknowledge that no guarantee has been made to me regarding the outcome of the procedure.

I authorize the dental provider listed above and their designated staff to perform the procedure described, to administer and monitor anesthesia as indicated, and to perform such additional or different procedures as are necessary or advisable in the exercise of professional judgment to address unforeseen conditions, and I consent to such treatment.

I acknowledge and consent to the treatment described above and the administration of anesthesia as necessary.

HIPAA Privacy and Authorization

I acknowledge that I have received or been offered a copy of the dental practice's Notice of Privacy Practices that describes how my health information may be used and disclosed. I authorize the release of my dental and medical information to my insurance company as necessary for claims and payment.

I authorize the following persons to receive information about my appointment, treatment, and billing:

Financial Responsibility

I understand I am responsible for payment of all charges for dental services provided to me, including charges not covered or reimbursed by my insurer. Payment policies, co-payments, deductibles, and applicable fees have been explained to me.

I accept financial responsibility for services rendered and understand the practice's billing policies.

Patient Certification

I certify under penalty of perjury that the information I have provided on this form is true and correct to the best of my knowledge. I have read and understand the foregoing and freely consent to the procedures and authorizations described herein.

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