Dental Informed Consent
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Is the patient minor?
Parent/Guardian or POA Information
Primary Phone Number
Secondary Phone Number
Dental Procedure Details
Type of Dental Procedure
Regular Hygiene Visit
Crown or Bridge
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Acknowledgment and Waiver
Type a question
I allow and authorize Aldershot Dental Hygiene to perform this procedure to me. The doctor or hygienist explained the nature of the treatment and how it will help me.
I allow Aldershot Dental Hygiene or the dentist to administer local anesthesia and understands the side effects of the medications given to me.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I acknowledge that all information I provided in this form is true and accurate.
I have filled out and submitted my medical history in full to the clinic previous to my appointment
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