Self Assessment
Choose Consent Form
INFORMED CONSENT FOR FINAL CEMENTATION
Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:
Registration Time:
INFORMED CONSENT FOR FINAL CEMENTATION
I, the undersigned, acknowledge that the nature and type of material to be used in my cosmetic veneers, or crowns, or bridges, etc., such as EMAX, zirconia, all porcelain, etc., has been thoroughly explained to me.
By signing below, I provide my consent and authorize the use of the specified material in my mouth.
I have been given the opportunity to examine my veneers, either on models or in my mouth, prior to final cementation. I confirm my satisfaction with the color, shape, feel, and overall appearance of the veneers. I understand that once the veneers are cemented in place, changes to the color, shape, feel, or overall appearance may require additional time and fees. Furthermore, I am aware that the removal of cemented veneers carries the risk of injuring or damaging the underlying teeth, resulting in the need for replacement.
By signing this Consent for Final Cementation, I grant my dentist and his/her assistant full consent for the final cementation procedure. I acknowledge my approval of the appearance and color of the veneers and authorize the use of the aforementioned material.
Please note that once treatment is completed, a strict no-refund policy applies. I understand that refunds will not be issued after the completion of the treatment.
I understand that the responsibility for the outcome of the treatment lies with me, the patient, and upon my request, I am proceeding with the treatment under my own responsibility.
By signing below, I acknowledge that I have read and fully understood the information provided in this consent form. I voluntarily consent to undergo the final cementation procedure, acknowledging the associated risks and potential complications. I accept financial responsibility for the treatment and any additional procedures that may be required. I release the dental
Patient Name:
Signature
Date
Witness Name
Signature
Date
Doctor name :
Dr.
Signature
Date
Patient Signature
Witness Signature
Print