Healthcare Dental-Vision Consent Form

Healthcare Dental‑Vision Consent Form

Patient Information

Patient Name:    Date of Birth:

Gender:    Phone:

Insurance Information

Medical History

Are you pregnant or nursing? Yes No

Consent for Dental Services

I authorize the provision of diagnostic, preventive, and therapeutic dental services including examinations, radiographs (x‑rays), prophylaxis (cleaning), topical fluoride, restorations (fillings), extractions, and administration of local anesthesia as indicated by the provider. I understand that additional or unforeseen treatment may be required and that I will be informed when possible.

Specific dental services to be provided (check all that apply):

Dental Exam    X‑rays    Cleaning/Prophylaxis    Fillings/Restorations

Extraction    Local Anesthesia    Nitrous Oxide / Conscious Sedation (if available)

Consent for Vision Services

I authorize the provision of vision care including comprehensive eye examination, refraction for eyeglass or contact lens prescription, ocular health evaluation, diagnostic imaging and dilation when indicated. I understand dilation may blur vision temporarily and may affect ability to drive.

Specific vision services to be provided (check all that apply):

Eye Exam    Dilation    Refraction (Glasses Rx)

Contact Lens Fitting    Diagnostic Imaging (OCT, photos)

Risks, Benefits, and Alternatives

The benefits of treatment include improved oral and visual health, prevention of disease progression, pain relief, and improved function. Material risks include, but are not limited to: infection, bleeding, nerve injury, allergic reaction, temporary or permanent numbness, failure of treatment to achieve desired result, and vision changes following dilation or procedures. Alternatives include no treatment, alternative procedures, or referral to a specialist. I understand no guarantee has been made regarding outcomes.

Consent to Use of Photographs and Records

I authorize clinical photographs, digital images, and diagnostic records to be taken as necessary for my care and for inclusion in my health record. Such images may be used for diagnosis, treatment planning, and quality assurance. I understand identifiable images will not be used for teaching or publication without separate written consent.

Release of records to third parties: I authorize release of my dental and vision records to the following person(s) or entity(ies) for continuity of care:

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I may obtain access to this information. I understand I may revoke authorizations in writing except to the extent action has been taken in reliance thereon.

Patient acknowledges and agrees to electronic communication of appointment reminders and limited clinical information via phone, text, or email unless otherwise specified.
I acknowledge receipt and understanding of the notice of privacy practices.

Financial Responsibility and Assignment

I accept financial responsibility for services rendered. I authorize payment of insurance benefits to the treating provider where applicable and agree to pay any co‑payment, deductible, or non‑covered services. I understand I am responsible for collection or legal costs should my account be referred for collection.

I authorize the assignment of insurance benefits to the provider and accept financial responsibility.

Patient Certification and Consent

By signing below I certify that I have read and understand this form, that the information I provided is complete and accurate to the best of my knowledge, and that all my questions have been answered. I consent to the providers named or their designees performing the dental and/or vision care indicated above. I understand I may withdraw this consent in writing at any time, except to the extent that action has already been taken in reliance on it.

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