Patient Registration Form

Please correct the errors described below.

Patient information

Insurance Information

Please be advised that our office requires a 48 hour notice for cancellation. A $50.00 fee may be charged for appointments cancelled without notice or no-shows.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Health History

To the best of my knowledge, the questions on the form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dentist office of any changes in my medical status.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Consent Form for Dental Treatment

Drugs and Medications

Changes in Treatment Plan

Removal of Teeth

and any others necessary for reasons in paragraph #3. I understand that removing teeth does not always remove all of the infection, if present, and it may be necessary to have further treatment. I understand the risk involved in having teeth removed, some of which are pain swelling, the spread of infection, dry socket, loss of feeling in my teeth, lips tongue and surrounding tissue (Paresthesia) that can last for complications arise during or following treatment, the cost of which is my responsibility.

Crown, Bridge(s), Veneers and Cap(s)

Dentures, Complete or Partial

I realize that full or partial denture(s) are artificial, constructed of plastic, metal, and /or porcelain. The problems of wearing these appliances have been explained to me including looseness, soreness, and breakage. I realize the final opportunity to make changes in my new dentures in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.

Endodontic Treatment (Root Canal)

I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally additional surgical procedures may be necessary following root canal treatment. (Apioectomy)

Periodontal Loss (Tissue & Bone) I understand that I have a serious condition, causing gum and bone infection 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.

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 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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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