Dental Treatment Consent Form

Please correct the errors described below.

Treatment Plan

Drugs and Medications

Changes in Treatment Plan

Prior To Treatment

Caffeine/Medications

Pre-Med - Amoxicillin/Clindamycin.

Sedative – (Valium).

Nitrous Oxide (Laughing Gas)

Fillings

Amalgam(silver)

Resin(white)

Major Restorations

Crowns (Caps)

Bridges

Implants

Dentures, Complete or Partials

Endodontics

Root Canals

Oral Surgery

Extractions

Periodontics

Scaling/Root Planing (Deep Cleaning)

Orthodontics

Invisalign

Whitening

Teeth Whitening (Bleaching)


I understand that dentistry is not an exact science. Therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the 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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