Dental Treatment Consent Form

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DENTAL TREATMENT CONSENT FORM
Please read and initial the items checked below
and read and sign the section at the bottom of form.
Patient Name _____________________________
1. WORK TO BE DONE
I understand that I am having the following work done: Fillings _____ Bridges_______ Crowns_______
Extractions_______ Impacted teeth removed_______ General Anesthesia__________ Root Canals_______
Dental Examination________ Dental Prophylaxis (Dental Cleaning) ________ X-ray________
(Initials____________)
2. DRUGS AND MEDICATIONS
I understand that antibiotics and analgesics and other medications can cause allergic reactions causing
redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (Severe allergic
reaction).
(Initials____________)
3. CHANGES IN TREATMENT PLAN
I understand that during treatment it may be necessary to change or add procedures because of
conditions found while working on the teeth that were no discovered during examination, the most
common being root canal therapy following routine restorative procedures. I give my permission to the
Dentist to make any/all changes and additions as necessary.
(Initials____________)
4. PERIODONTAL LOSS (TISSUE & BONE)
I understand that I have a serious condition, causing gum and bone infections or loss and that it can
lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum
surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have
a future adverse effect on my periodontal condition.
(Initials____________)
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot
fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding
the dental treatment which I have requested and authorized. I have had the opportunity to read this form
and ask questions. My questions have been answered to my satisfaction. I consent to the proposed
treatment.
Signature of Patient ______________________________________________ Date__________________
Signature of Parent/Guardian if patient is a minor______________________ Date___________________

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