Healthcare Dental Waiver

Healthcare Dental Waiver

Patient Information

Patient Name:

Date of Birth:     Gender:

Emergency Contact

Insurance Information

Medical History / Current Health

Pregnant or suspect pregnancy? Yes    If yes, number of weeks:

Procedure / Treatment

Estimated Procedure Date:     Local anesthesia anticipated?     Sedation anticipated?

Risks, Benefits, and Alternatives

I acknowledge that the practice of dentistry is not an exact science and that no guarantee has been made to me as to the results of the proposed procedure(s). The known risks and complications include, but are not limited to: infection, prolonged bleeding, swelling, discomfort, nerve damage resulting in numbness or altered sensation, fracture of teeth or bone, incomplete resolution of the presenting condition, need for further treatment, reaction to medications or anesthetics, and temporomandibular joint symptoms. Serious but rare complications may include hospitalization or permanent injury.

Alternatives to the proposed procedure(s) have been explained to me, including the option of no treatment and the potential consequences of delaying or refusing treatment.

I acknowledge receipt of an explanation of risks, benefits and alternatives and have had an opportunity to ask questions and have them answered to my satisfaction.

Acknowledgement of understanding: I have read and understand the risks, benefits and alternatives described above.

Consent, Waiver, and Release

By signing this Dental Waiver I authorize the dental care team to perform the procedure(s) described above and to administer such local or other anesthetic, medications, and dressings as the treating dentist deems necessary. I accept and assume the risks associated with these procedures. To the fullest extent permitted by law, I release and hold harmless the dentist, dental practice, and their agents, employees, and contractors from liability for any complications, injuries, or claims arising out of the performance of the agreed treatment, except in cases of gross negligence or willful misconduct.

I understand that this waiver and release affects my legal rights and that I may wish to consult with an attorney before signing. I further acknowledge that I have provided a complete and accurate medical and dental history and I will notify the dental office of any changes in my health status prior to treatment.

Consent to radiographs and clinical photographs: I consent to necessary radiographs and photographs for diagnosis, treatment, recordkeeping, and insurance purposes. I understand images may be retained in my chart.

Financial Responsibility

I accept financial responsibility for services rendered and understand that my dental insurance is a contract between myself and my insurer. I authorize release of information necessary to process my insurance claims. I understand that I am responsible for any portion not covered by insurance, including deductibles, co-payments, and non-covered services.

Financial acknowledgement: I agree to be financially responsible for all charges not paid by insurance.

HIPAA / Privacy & Authorization

I acknowledge that I have been offered a copy of the dental practice's Notice of Privacy Practices, describing how my protected health information may be used and disclosed, and my rights with respect to that information. I understand that the practice may contact me by telephone, mail or electronic means for scheduling and follow-up.

Authorization for release of records to insurer: I authorize release of my dental records and claims information to my insurance carrier and their agents as necessary for claims processing.

Acknowledgements

Right to withdraw: I understand I may withdraw my consent at any time prior to the procedure by notifying the dental practice in writing, except where action has already commenced and withdrawal may not negate charges for services rendered.

Patient questions: I have had the opportunity to ask questions about the proposed care and my questions have been answered to my satisfaction.

If signing as guardian, check and complete: I am the legal guardian or authorized representative of the patient and have authority to sign on their behalf.

Patient Certification

I certify that I have read and fully understand the contents of this Dental Waiver, that the information I have provided is true and complete, that all my questions have been answered, and that I freely consent to the proposed treatment and accept the terms set forth above.

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