Informed Consent For Full And/or Partial Dentures Form (Page 2 of 2) in pdf

Informed Consent For Full And/or Partial Dentures Form Page 2

PLEASE INITIAL EACH OF THE FOLLOWING:

X______ I CONSENT TO THE ADMINISTRATION TO SUCH LOCAL ANESTHESIA AS DEEMED

NECESSARY BY THE ABOVE NAMED DOCTOR TO ACCOMPLISH THE PROPOSED

PROCEDURE.

X_____ I HAVE HAD AN OPPORTUNITY TO DISCUSS WITH THE DOCTOR MY PAST MEDICAL

AND HEALTH HISTORY INCLUDING ANY SERIOUS PROBLEMS AND INJURIES.

X_____ I AGREE TO COOPERATE COMPLETELY WITH THE RECOMMENDATIONS OF THE

DOCTOR WHILE I AM UNDER HIS / HER CARE, REALIZING THAT ANY LACK OF THE

SAME COULD RESULT IN A LESS THAN OPTIMUM RESULT.

X_____ DUE TO INDIVIDUAL PATIENT DIFFERENCES THERE EXISTS A RISK OF FAILURE,

RELAPSE, NEED FOR SELECTIVE RE-TREATMENT, OR WORSENING OF MY PRESENT

CONDITION WOULD OCCUR SOONER WITHOUT THE RECOMMENDED TREATMENT.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ FULLY AND UNDERSTAND THE

TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE PROCEDURE AND THE

EXPLANATION REFERRED TO OR MADE. ALL BLANKS OR STATEMENTS REQUIRING

INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY,

WERE STRICKEN BEFORE I SIGNED. I ALSO STATE THAT I READ AND WRITE ENGLISH.

I GIVE CONSENT FOR THE TREATMENT AS DESCRIBED ABOVE.

I REFUSE TO GIVE MY CONSENT FOR THE PROPOSED TREATMENT AS DESCRIBED

ABOVE. I HAVE BEEN EXPLAINED AND UNDERSTAND THE POTENTIAL

CONSEQUENCES OF MY CHOICE.

X______________________________________________ X________________________________

PATIENT, PARENT, GUARDIAN

DOCTOR

X______________________________________________ X_________________________________

WITNESS

DATE

birthday

*MINOR-Any unmarried male or female that has not reached their 18

**Patient is to initial each paragraph after reading

Informed Consent For Full And/or Partial Dentures Form Page 2