Dental Cleaning Release Form

Dental Cleaning Release Form
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Are you currently under the care of a physician?
YesNo
If yes, please provide the name and contact information of your physician.
Do you have any allergies to medications or materials used in dental procedures?
YesNo
If yes, please specify
Are you currently taking any medications?
YesNo
If yes, please list medications
Dental Cleaning Consent:
I, [Patient's Name], understand that a dental cleaning procedure involves the removal of plaque, tartar, and stains from the teeth to maintain oral health. I understand that while the dental cleaning procedure is generally safe, there may be risks and potential complications, including but not limited to:
- Gum irritation or bleeding
- Tooth sensitivity
- Jaw pain or discomfort
- In rare cases, infection or damage to dental structures
I understand that the dental hygienist will use dental instruments and devices to perform the cleaning procedure and may recommend additional treatments or procedures based on the findings during the cleaning.
I acknowledge that I have been provided with information about the dental cleaning procedure and have had the opportunity to ask questions and seek clarification about the procedure, risks, and alternatives.
I consent to undergo the dental cleaning procedure and authorize the dental hygienist to perform the necessary cleaning and related treatments.
Patient Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty: