Dental Consent Form
Dental Consent Form
Please carefully read the information provided and fill out this form completely to obtain your consent for dental procedures and treatments.
Personal Information
Name
Date of Birth
Phone number
Dental Procedure Information
Procedure Name
Date of Procedure
Dentist’s Name
Purpose of Consent
The dental procedure will be performed for the following purposes:
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To treat dental disease, infection, or decay.
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To improve oral health and function.
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For cosmetic enhancements, such as teeth whitening or veneers.
Risks and Benefits
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I have been informed of the risks, benefits, and alternatives associated with the procedure.
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I understand that there may be discomfort, sensitivity, or complications during or after the treatment.
Consent Options
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I consent to the recommended dental procedure and any necessary additional treatment.
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I do not consent to the dental procedure at this time.
Terms and Conditions
By signing below, you acknowledge that:
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You have discussed the procedure, risks, and alternatives with your dentist.
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You understand the purpose, process, and potential outcomes of the dental treatment.
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Your consent is voluntary and can be withdrawn at any time before the procedure.
Signature
Name:
Date:
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