Dental Informed Consent Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient minor?
Yes
No
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Primary Phone Number
Secondary Phone Number
Dental Procedure Details
Type of Dental Procedure
Tooth Extraction
Grafting
Restoration
Cosmetic Dentistry
Implants
Prosthetics
Oral Sedation
Treatment
Root Planing
Do you have any allergies?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Acknowledgment and Waiver
1
I allow and authorize (Dental Care Clinic) to perform this procedure to me. The doctor explained the nature of the treatment and how it will help me.
I allow (Dental Care Clinic) to administer anesthesia and understands the side effects of the medications given to me.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I understand that I am not allowed to eat or drink 4-6 hours before the procedure.
I acknowledge that all information I provided int his form is true and accurate.
Patient/Parent/Guardian Signature
Signed Date
-
Month
-
Day
Year
Date
Submit
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