General Informed Consent for Examination and Treatment

The purpose of this informed consent form is to provide an opportunity for patients (and/or their guardians) to understand and give permission for the performance of general services involved in dental care.

I understand and accept that Dr. Divya Mudumba DMD and/or the providers of Smileworks Family Dentistry will, in the course of their clinical duties, perform: a. Examination and diagnosis of oral health b. Prophylactic teeth cleaning c. Diagnostic X-rays (radiographs) d. Intra- and extra-oral photography e. Treatment planning f. Use of local anesthetics and basic restorative and preventative procedures.

I understand and accept that in regards to photography (both intra- and extra-oral), I consent to the use of these images for patient identification, documentation of oral conditions and treatment, and/or for communication with dental laboratories or other healthcare providers.

I understand that payment is due at the time of services rendered and that I am responsible for payment of all dental fees not paid in full by any insurance or other applicable coverage. I hereby allow Smileworks Family Dentistry P.C. to bill my insurance provider, if any.

By signing this form, I freely give my consent to authorize the providers at Smileworks Family Dentistry to render my treatment as necessary or advisable for my dental conditions, including any and all anesthetics and/or medications. I understand that my informed consent for examination, diagnosis, and treatment shall remain in effect until I am no longer regarded as a patient of record.

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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General Informed Consent for Examination and Treatment

Smile Works Family Dentistry