Healthcare Dental Procedure

DENTAL PROCEDURE CONSENT AND AUTHORIZATION

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Subscriber Date of Birth:

Medical History

Do you believe you may be pregnant? Yes No

History of bleeding disorders: Yes No

Procedure Details

Tooth/Teeth involved:    Proposed Procedure Date:

Estimated Fee: $

Options to be used: Local anesthesia IV or oral sedation General anesthesia

Risks, Benefits, and Alternatives

I acknowledge that the proposed dental procedure, its associated anesthesia and adjunct treatments carry risks that may include, without limitation: infection, bleeding, swelling, persistent pain, prolonged numbness or altered sensation due to nerve injury, fracture of tooth structure or jaw, sinus complications, failure of the procedure, need for additional or alternative procedures, adverse reaction to medications or anesthesia, and scarring. Rare but serious complications, including hospitalization or death, are possible.

The anticipated benefit(s) of the procedure include improvement in dental health, relief of pain, restoration of function and/or aesthetics. Reasonable alternatives to the proposed procedure include: no treatment, monitoring, less invasive restorative care, extraction, or referral to a specialist. No guarantee or assurance has been made to me as to result or cure.

I have been given the opportunity to ask questions about the procedure, alternatives, risks and expected benefits, and my questions have been answered to my satisfaction. I understand that I may withdraw this consent at any time prior to the procedure by providing written notice, but withdrawal will not affect actions already taken in reliance on this consent.

Acknowledgment of Risks and Alternatives: I acknowledge that I have read and understand the risks, benefits and alternatives described above.

Authorization and Releases

Authorization to Perform Procedure: I authorize the dentist(s), assistants, and other personnel to perform the procedure described above and to use such local, sedative or general anesthetic agents as deemed necessary. I authorize administration of prescribed medications, local anesthesia, nitrous oxide or sedation as indicated.

Radiographs and Photographs: I consent to the taking and use of radiographs, photographs, digital images and videos before, during and after treatment for diagnostic, treatment planning, documentation, and educational purposes. I understand that such records are the property of the dental practice but may be released to my insurer or other providers as necessary for treatment or billing.

Assignment and Release for Insurance: I authorize release of information necessary to process claims and request payment of benefits to the provider. I understand I remain financially responsible for charges not covered by insurance and agree to pay all fees charged for services rendered.

Authorization Expiration: This authorization will remain in effect until: unless earlier revoked in writing by the patient.

HIPAA and Privacy Acknowledgement

I acknowledge receipt of the dental practice's Notice of Privacy Practices and consent to the use and disclosure of my protected health information for purposes of treatment, payment and healthcare operations as described in that notice. I understand my rights regarding my protected health information and that I may request restrictions in writing which the practice may accept or deny.

HIPAA Acknowledgement: I acknowledge and consent to the uses and disclosures described above.

Additional Consents

Photo/Video for Educational Use: I consent to de-identified photos/videos being used for educational purposes   I do not consent

Release for Emergency Treatment: I authorize emergency treatment as necessary in the event of an adverse reaction or unforeseen complication.

Certification and Consent

By signing below I certify that I have read and fully understand this consent form, that all of my questions have been answered, and that no guarantees or promises have been made to me regarding the outcome. I consent to the dental treatment described above and authorize release of information as necessary for treatment and billing.

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