Consent Form Dental Implant(S) (Page 4 of 4) in pdf

I give permission for persons other than the doctors involved in my care and treatment to observe this operation

(such as company representatives and dentists who are learning the procedure), and I consent to photography,

filming, recording, and x-rays of my oral and facial structures and the procedure. Their publication for

educational and scientific purposes is authorized, as long as my identity is not revealed. I give up all rights for

compensation for publication of these records.

If teeth are removed during treatment, they may be retained for training purposes and then disposed of

sensitively.

Fees

I know the fee that I am to be charged. I am satisfied with it and know that it does not include additional

postoperative x-rays, injections, or anesthetics that may later be necessary to correct any complications. As a

courtesy to me, the office staff will help prepare and file insurance claims should I be insured. However, the

agreement of the insurance company to pay for medical expenses is a contract between myself and the

insurance company and does not relieve my responsibility to pay for services provided. Some, and perhaps all,

of the services provided may not be covered or not considered reasonable and customary by my insurance

company. I am responsible for paying all co-pays and deductibles at the time services are rendered and all costs

that have not been paid for by my insurance company within 45 days. Otherwise, all payments are due at the

time services are rendered. All accounts not paid in full within 90 days shall accrue interest at the rate of 18%

per .year. I will be liable for all collection costs, including court costs and attorney fees.

Part 5—Signature Understanding

I read and write English. I have read and understand this form. All blanks or statements requiring insertion or

completion were filled in and inapplicable paragraphs, if any, were stricken before I signed.

I have been encouraged to ask questions and am satisfied with the answers. I have read this entire form.. I give

my informed consent for surgery and anesthesia.

Someone at the doctor's office has explained this form, my condition, the procedure, how the procedure may

help me, things that can go wrong, and my other options, including not having anything done. I want to have the

procedure done.

I authorize Dr. Duc Huynh or his designee (referred to in the rest of this form as the doctor) to perform the

procedure listed in the title above.

I know that I am free to withdraw from treatment at any time.

____________________________

_______________

Patient or Representative Signature

Date

If not the patient, what is your relationship to the patient?

_____________________________________________

I have explained the condition, procedure, benefits, alternatives, and risks described on this form to the patient

or representative.

________________________

_______________

Dentist Signature

Date

Consent Form Dental Implant(S) Page 4