Healthcare Dental Group Consent Form

HEALTHCARE DENTAL GROUP CONSENT FORM

Patient Information

Patient Name:

Male Female Other Prefer not to say

Insurance Information

Medical History

Are you pregnant? Yes No

Do you use tobacco products? Yes No

Procedure / Treatment Authorization

Proposed date of procedure:    Tooth/Area:

Risks, Benefits and Alternatives

I acknowledge that the practitioner has explained the nature and purpose of the proposed dental procedure(s), the expected benefits, the probable risks, and reasonable alternatives. Potential risks include, but are not limited to: postoperative pain, swelling, infection, bleeding, nerve injury resulting in numbness or altered sensation, tooth or root fracture, failure of restoration or treatment, need for additional procedures, allergic reaction, and anesthetic complications. No guarantee or assurance has been made as to the results that may be obtained.

I have read and understand the risks described above and have had the opportunity to ask questions.

Alternatives to the proposed treatment, including the option of no treatment, have been discussed with me. I understand the risks and benefits of the alternatives.

I understand the alternatives and consent to the recommended procedure.

Anesthesia / Sedation

I consent to administration of local anesthesia and any adjunctive medications deemed necessary by the dental team. I understand that all anesthesia carries some risk, including allergic reaction, respiratory depression (with sedatives), nausea, and rare serious complications.

Anesthesia requested/authorized: Local anesthesia Nitrous oxide/oxygen IV sedation/General anesthesia

Financial Responsibility

I understand that I am financially responsible for all charges associated with my care and that payment is due as described by the practice. Assignment of benefits to the practice is authorized where applicable, but I remain responsible for any portion not covered by insurance, including co-payments, deductibles, and services denied by my insurer.

I accept financial responsibility for services rendered.

Authorization for Release of Information and Photography

I authorize Healthcare Dental Group to release my dental and medical information to my insurance carrier(s) and other providers for treatment, payment, and healthcare operations. I further authorize the taking of clinical photographs, radiographs, or digital images for diagnosis, treatment planning, and legitimate educational or scientific purposes; such images that identify me will not be used without additional explicit consent unless required for treatment or quality assurance.

I authorize release of information as described above.

HIPAA Acknowledgment

I acknowledge that I have been offered or received the practice's Notice of Privacy Practices which explains how my health information may be used and disclosed and how I can access this information. I understand my rights regarding my protected health information and that I may request additional restrictions in writing.

I acknowledge receipt of the Notice of Privacy Practices or I have been given the opportunity to review it.

Emergency Treatment Authorization

In the event of an emergency arising during dental treatment, I authorize Healthcare Dental Group and its staff to provide or arrange for immediate medical care they deem necessary. I understand such emergency care may include transport to an emergency facility.

I authorize emergency treatment as described above.

Patient Certification

By signing below I certify that I have read and understand this Consent Form in its entirety, that all my questions have been answered to my satisfaction, and that I give informed consent for the dental procedure(s), anesthesia, release of information, and financial responsibility as indicated above. I also certify that the information I have provided on this form is true and correct.

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