Waiver of Proper Dental Treatment

Waiver of Proper Dental Treatment
I understand that I am about to receive treatment on tooth:
which is not a standard acceptable treatment for the care and protection of this tooth. I understand that by my election of this lower level of treatment, my tooth is more susceptible to damage which could lead to the loss of this tooth. I understand the work done today on this tooth is in no way guaranteed.
I also understand that if I later elect to take the standard acceptable course of treatment with this tooth, any work done today may or may not be financially credited to that acceptable course of treatment.
By signing below, you have read, and understand this agreement.
Patient Name
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Signature of Responsible Party
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Date
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Date
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