Standard Dental Treatment Consent Form

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Standard Dental Treatment Consent Form
We are complimented that you have selected us to provide dental care for
you.
The undersigned hereby authorizes doctor to take x-rays, study models,
photographs, or any other diagnostic aids deemed appropriate by doctor to
make a thorough diagnosis of the patient’s dental needs.
I authorize doctor to perform all recommended treatment mutually agreed
upon by me and to use the appropriate medications and therapy indicated for
such treatment in connection with (name of patient) ___________________.
I understand that using anesthetic agents embodies a certain risk. Further-
more, I authorize and consent that doctor choose and employ such assistance
as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for dental services provided
in this office for myself or my dependents is mine, due and payable at the
time services are rendered unless other arrangements have been made. In
the event payments are not received by the agreed upon dates, I understand
that a one and a one half percent monthly finance charge (18% APR) will be
added to my account, and I agree to pay it.
I understand and agree that where appropriate, credit bureau reports may be
obtained.
_____________________________________________________________
Patient
Date
Witness
_____________________________________________________________
Parent or Responsible Party
Relationship to Patient

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