Dental Informed Consent
Patient Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient minor?
Yes
No
Parent/Guardian or POA Information
Parent/Guardian/POA Name
First Name
Last Name
Primary Phone Number
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Dental Procedure Details
Type of Dental Procedure
Regular Hygiene Visit
Restoration
Cosmetic Dentistry
Dentures
Whitening Treatment
Custom Mouthguard
Crown or Bridge
Other
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
Patient/Parent/Guardian/POA Signature
Signed Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: