To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.
If you are completing this form for another person, what is your name and relationship to that person?
If executing this form as the patient's personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.
Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).
Please use an “X” to mark your answers to the following questions
NOTE: It’s important for both the doctor and patient to talk honestly about the patient's health before dental treatment starts.I have answered the above questions completely, accurately and to the best of my ability.
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