Informed Consent Discussion For Denture(S) (Page 4 of 4) in pdf

Informed Consent Discussion For Denture(S) Page 4

No guarantee or assurance has been given to me by anyone that the proposed treatment will cure or improve the

condition(s) listed above. I have had my questions answered to my satisfaction.

□

I have been given the opportunity to ask questions and give my consent for the proposed treatment as

described above.

□

I refuse to give my consent for the proposed treatment(s) as described above and understand the potential

consequences associated with this refusal.

_____________________________________________

__________________

Patient’s Signature (or Patient’s Representative)

Date

I attest that I have discussed the risks, benefits, consequences, and alternatives of dentures with

______________________________(Patient’s name), who has had the opportunity to ask questions, and I believe

my patient understands what has been explained.

____________________________________________

__________________

Dentist’s Signature

Date

____________________________________________

__________________

Witness’ Signature

Date

Dentures

09/09

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Informed Consent Discussion For Denture(S) Page 4