Healthcare Patient Dental Treatment Consent

HEALTHCARE PATIENT DENTAL TREATMENT CONSENT

Patient Information

Insurance Information

Medical History

Are you pregnant or breastfeeding? Yes No

Treatment and Consent

I, the undersigned, authorize the dental practitioner and staff to perform the following procedure(s) and any additional procedures deemed necessary for safe and effective treatment:

Explanation of Risks and Benefits: The risks, probable results, and alternatives to the proposed treatment, including no treatment, have been explained to me. Known risks may include, but are not limited to: infection, bleeding, swelling, nerve injury, tooth fracture, sensitivity, need for additional procedures, allergic reaction, and failure to achieve desired results. There is no guarantee that the proposed treatment will be successful.

The benefits of the treatment were explained, including restoration of oral health, relief of pain, and improved function or esthetics where applicable. I have had the opportunity to ask questions and all questions have been answered to my satisfaction.

Consent for Ancillary Procedures (check all that apply):
Local anesthesia Nitrous oxide / conscious sedation Intravenous sedation / general anesthesia Dental radiographs (x-rays) Clinical photographs for records and treatment planning

I authorize the dentist to administer anesthesia and medications as deemed necessary. I understand that all forms of anesthesia have risks and that I will remain under observation as required. I acknowledge that if intravenous or general anesthesia is to be used, a separate pre-anesthesia evaluation and consent may be required.

Financial Responsibility

I certify that I am financially responsible for all charges for dental services provided to me or my dependent. Insurance estimates are not a guarantee of payment. I authorize release of information necessary to process insurance claims and I authorize payment of benefits to the treating dentist unless otherwise specified in writing.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how my health information may be used and disclosed and how I can obtain access to this information.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization and Expiration

By signing below I authorize the performance of the treatment and ancillary procedures described above. I understand that I may withdraw this authorization at any time by giving written notice, except to the extent that action has already been taken in reliance on this consent.

Initial to indicate you have read and understand the foregoing consent and acknowledgments:

If signing for a minor or an adult who is unable to sign, indicate relationship:

Attestation

I attest that the information I have provided on this form is true and complete to the best of my knowledge. I understand the nature of the proposed treatment, the risks and benefits, and the alternatives. I authorize release of my dental and medical information to insurers and other health care providers as necessary for treatment and payment purposes.

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