Allard Station Dental Treatment Consent And Office Policy

Treatment Consent
I, the undersigned authorize Allard Station to perform any necessary dental services and oral surgery that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all dental services are my sole responsibility and that I should make myself aware of any fees associated with my dental care prior to treatment.
Signature:
Print Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Policy
Your appointment time will be reserved especially for you. If you are unable to keep your scheduled visit, we ask for 2 business days’ notice. Advance notice allows our office to see other patients who may have been waiting for us for needed treatment. We thank you in advance for your consideration.
Should be Empty: