DENTAL CONSENT FORM
- I have fully and correctly informed about all my Medical History
- I assure I will always update my Medical History on my future visits, and I understand that withholding information or providing misinformation may result in contraindication and/or irritation to any dental treatments received.
- I have had an opportunity to have my questions answered regarding the proposed procedure. I, therefore, give consent to having my advised dental procedure.
- I acknowledge that I have read and understood all the information provided and feel free that the doctor has adequately informed me regarding the risks of the treatment, alternative methods of the treatments, as well as the risk of unsuccessful treatment.
- I hereby authorize and direct Medical Village dental doctor to perform the treatments and assume full responsibility thereof.
- I agree about the price, and the VAT will be added to it for cosmetic treatment.
- There are no refunds/transferable for services rendered.
- The treatment I receive here is voluntary, and I release this institution from liability and assume full responsibility thereof.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :