Online Patient Form

Patient Name *

First Name Middle Name Last Name

Consent Form for General and Surgical

Dental Procedures

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You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

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Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

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It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow you dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialist, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

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Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary.

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The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

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If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.

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Further, I understand that I am entering into a contractual relationship with Dr. Darryl Azouz for professional care. I further understand that meritless and frivolous claims for dental malpractice have an adverse effect upon the cost and availability of dental care, and may result in irreparable harm to a dental provider. As additional consideration for professional care provided to me by Dr. Darryl Azouz, I agree not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical/dental malpractice against Dr. Darryl Azouz.

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Furthermore, should a dental malpractice case or cause of action be initiated or pursued, I agree to use expert witness(es) who practice primarily in the same specialty as Dr. Darryl Azouz. Furthermore, I agree that these expert witnesses will be members in good standing of the adhere to the guidelines and/or code of conduct defined for expert witness by the AMERICAN ACADAMY OF OZONE THERAPY, INTERNATIONAL ACADAMY OF ORAL & TOXICOLOGY, INTERNATIONAL ACADEMY OF BIOLOGICAL DENTISTRY & MEDICINE AND HOLISTIC DENTAL ASSOCIATION, In further consideration for this, Dr. Darryl Azouz agrees to the same stipulations.

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I acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Doctor's reputation and business. Both Dr. Darryl Azouz and I agree in the event of a breach to allow specific performance and/or injunctive relief.

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As with all healthcare treatment, there are commonly known risks and potential complications associated with the dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less that optimal result. Even though many of these complications are rare, they can and do occur occasionally.

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Some of the more commonly known risks and complications of treatment include, but are not limited to the following:

Pain swelling and discomfort after treatment
Infection in need of medication, follow-up procedures or other treatment.
Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums and tongue along with possible loss of taste.
Damage to adjacent teeth, restorations or gums.
Possible deterioration of your condition which may result in tooth loss.
The need for replacement of restorations, implants or other appliances in the future.
An altered bite in need of adjustment.
Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist.
A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed at a later time if symptoms develop
Jaw fracture
If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment.
Allergic reaction to anesthetic or medication
Need for follow-up treatment, including surgery.

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This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

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(Your digital signature (full name) is as legally binding as a physical signature.)