Healthcare Dentist Consent Form

DENTAL TREATMENT CONSENT AND AUTHORIZATION

Clinic/Practice Name:    Date of Visit:

Patient Information

Insurance Information

Subscriber Date of Birth:

Medical & Dental History

Are you currently taking any medications?   Yes   No

Allergies (check all that apply):

Proposed Treatment / Procedure

Expected benefits:

Risks, Complications and Alternatives

I understand that the practice of dentistry is not an exact science and that no guarantees have been made regarding results. Risks and complications associated with the proposed treatment may include, but are not limited to: infection, prolonged bleeding, swelling, sensitivity, pain, numbness or paresthesia of lips, tongue or chin (which may be temporary or permanent), tooth fracture, damage to adjacent teeth or restorations, sinus involvement, failure of the restoration or treatment, need for additional treatment, allergic reactions, and medical complications related to cardiovascular, respiratory or other systemic conditions.

Alternatives to the proposed treatment, including no treatment, have been explained to me and include: monitoring, alternative restorative or surgical options, or referral to a specialist. I have had the opportunity to ask questions and receive understandable answers regarding risks, benefits and alternatives.

I acknowledge that while every effort will be made to avoid complications, unforeseen events may occur requiring additional or different treatment than described above. I consent to such care, including the use of additional anesthesia or medications deemed necessary by the treating dentist in the event of an emergency.

I acknowledge that the risks, benefits, and alternatives have been explained to me and that my questions have been answered.

Anesthesia / Sedation

I consent to the administration of the following types of anesthesia or sedative agents as may be necessary or advisable for the proposed procedure (check all that apply):

I understand the risks associated with anesthesia/sedation include allergic reaction, respiratory depression, nausea, vomiting, aspiration, cardiovascular complications, and, rarely, death. The anesthetic plan and monitoring to be used have been described to me.

Authorization to Release and Financial Responsibility

I authorize the release of any dental or medical information necessary to process insurance claims and to coordinate care. I authorize payment of benefits directly to the treating practice for services rendered. I understand that I am financially responsible for all fees not paid by my insurance, including co-payments, deductibles, and procedures denied by payer.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices and that my protected health information may be used and disclosed for treatment, payment, and health care operations as described in that notice.

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

Right to Withdraw and Emergency Care

I understand that I may withdraw my consent in writing at any time, except to the extent that action has already been taken in reliance on this authorization. In the event of an emergency, I authorize the dentist and staff to provide necessary emergency treatment if I am incapacitated or otherwise unable to provide prompt direction.

I understand my right to withdraw consent and the provisions for emergency care.

This authorization for treatment, release of records and insurance processing will remain in effect until:

By signing below I certify that I have read and understand this consent, that the information provided is accurate to the best of my knowledge, and that I consent to the performance of the described dental treatment and any necessary or advisable adjunctive procedures.

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