Healthcare Dental GIP Template

DENTAL GIP INFORMED CONSENT AND AUTHORIZATION

Patient Information

Patient Name:    Date of Birth:

Gender: Male Female Other

Insurance Information

Medical & Dental History

Current Medications (name and dosage):

Allergies (medications, latex, materials):

Are you pregnant or attempting pregnancy? Yes   No

Tobacco use: Current    Former    Never

Procedure Description

Planned Procedure(s):

Teeth/Areas to be treated:    Estimated Duration:

Proposed Date of Procedure:

Anesthesia/Sedation to be used: Local Nitrous Oxide IV Sedation/General None

Risks, Benefits, and Alternatives

The undersigned acknowledges that the dentist has explained the nature of the proposed dental procedure(s), anticipated benefits, and reasonable alternatives including no treatment. Typical and significant risks include, but are not limited to: pain, swelling, bleeding, infection, prolonged healing, nerve injury resulting in altered sensation or paresthesia, need for additional procedures, anesthetic complications, and treatment failure. Some risks are rare but potentially serious.

Alternatives:

I acknowledge that no guarantee has been made as to the results of the procedure. I have been given an opportunity to ask questions and have had them answered to my satisfaction.

I acknowledge that risks, benefits, and alternatives were explained and I understand them.

Authorization & Release

Authorization for Treatment: I hereby authorize the dentists, dental hygienists, assistants, and other clinical personnel of this practice to perform the indicated dental procedures and to administer such anesthetic, sedative, and supportive measures as may be deemed necessary or advisable.

Assignment and Financial Responsibility: I accept financial responsibility for services rendered. I authorize assignment of benefits and direct payment of insurance proceeds to the provider, but remain responsible for any portion not covered by insurance.

Release of Records: I authorize the release of dental/medical information necessary for treatment, referral, billing, and insurance processing. This authorization is effective immediately and expires on:

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with the dental practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights regarding protected health information and that I may request restrictions or revoke authorizations in writing, subject to certain legal limitations.

I acknowledge receipt of the Notice of Privacy Practices or have been offered a copy.

Patient Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand the nature of the proposed treatment, the risks involved, the alternatives, and that I may withdraw consent at any time prior to treatment by notifying the provider. I authorize the listed providers to perform the treatment and related services as described above.

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