Dental Cosmetic Service Liability Waiver Form
Please complete this waiver before receiving dental cosmetic services. Provide accurate information about your treatment request and any relevant health disclosures.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Treatment Details
Dental cosmetic service requested
*
Teeth whitening
Veneers
Bonding
Contouring
Smile makeover
Other specified treatment
Preferred appointment date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical and Risk Disclosure
Which of the following apply to you?
*
Allergies
Current medications
Pregnancy or possible pregnancy
Existing dental conditions
Prior adverse reactions to dental materials or anesthetics
None of the above
Please provide brief details for any items selected above
Submit
Should be Empty: