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INFORMED CONSENT FOR GENERAL DENTAL PROCEDURE
Patient’s Name:
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Doctor Name:
Visit Date:
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INFORMED CONSENT FOR GENERAL DENTAL PROCEDURE
As a patient, you have the right to accept or reject dental treatment recommended by your dentist. Before providing consent for treatment, it is important to carefully consider the expected benefits, known risks of the recommended procedure, alternative treatments, or the option of no treatment.
Please do not provide consent for treatment until you have discussed the potential benefits, risks, and complications with your dentist, and all your questions have been answered. By giving consent, you acknowledge your willingness to accept known risks and complications, regardless of the probability of occurrence.
It is crucial to provide accurate information to your dentist regarding any medications you are currently taking, allergies to certain medications, any medical conditions you have before, during, and after the treatment, and regarding any pregnancy. Equally important is following your dentist's advice and recommendations regarding medication, pre and post-treatment instructions, referrals to other dentists or specialists, and attending scheduled appointments. Failure to follow your dentist's advice may increase the chances of an unfavorable outcome.
Furthermore, following your dentist's advice and recommendations, as well as attending scheduled appointments, is crucial for achieving optimal treatment outcomes.
1. Treatment to be Provided:
I understand that the following dental care may be provided during my treatment:
• Examinations
• Fillings
• Dental Surgery
• Preventive Services
• Crowns, Bridges, or Veneers
• Otherprocedures
1.
I am aware that, in the practice of dentistry, unexpected risks or complications may arise. I acknowledge that no guarantees or assurances have been made regarding the specific results that may be achieved.
2. Drugs and Medications:
I understand that antibiotics, analgesics, and other medications may carry the risk of allergic reactions, which can result in redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (a severe allergic reaction).
3. Changes in Treatment Plan:
I understand that during the course of treatment, it may be necessary to modify or add procedures based on conditions discovered while working on the teeth, which were not identified during the initial examination. One common example is the need for root canal therapy following routine restorative procedures. I hereby authorize the dentist to make any necessary changes and additions to the treatment plan.
4. Payment and Financial Responsibility:
I agree to assume full responsibility for the payment of all charges associated with the services performed. For dental prosthetic lab procedures (such as crowns or veneers), full payment is required prior to the fabrication process. I understand that there is a strict no-refund policy once treatment has been completed.
I also authorize the dental office to bill my dental insurance provider for the treatment provided, if applicable.
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 recommended treatment,acknowledging the associated risks and potential complications, as well as the absence of guarantees or assurances regarding the outcomes. I understand and accept financial responsibility for the treatment and any additional treatments required, and I release the dental clinic, its doctors, and staff from any liability arising from the treatment and its outcomes.
Patient Name:
Signature
Date
Witness Name
Signature
Date
Doctor name :
Dr.
Signature
Date
Patient Signature
Witness Signature
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