The patients or individuals willing to proceed with the treatment must be above 18 years to fill the form. For individuals below 18 years of age, their parents or guardians must fill the form.
Patient's Medical ID number
I authorize the release of any information necessary to process my insurance claims?
I hereby consent to the dental treatment(s) and/or procedure(s) and/or operation(s) and/or x-ray(s) and/or other diagnostic or therapeutic procedures, which the dentist or his designee may recommend or perform on me, and which are within the scope of dental practice. I understand that these procedures may involve risks, even though they are considered routine. These risks include, but are not limited to, infection, bleeding, reactions to drugs or materials used during treatment, and potential damage to adjacent teeth, gums, bones, or blood vessels. I have been given the opportunity to ask questions about the procedure(s), and I understand the nature of the procedure(s), the risks involved, and the possible consequences of not having the procedure(s) performed.