Dental Informed Consent Form
Patient Information
Name
First Name
Last Name
Patient No:
Age
Date of Birth
-
Month
-
Day
Year
Date
Is the patient under the age of 16?
Yes
No
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Primary Phone Number
Format: (000) 000-0000.
Dental Procedure Details
Type of Dental Procedure
Tooth Extraction
Grafting
Restoration
Cosmetic Dentistry
Implants
Prosthetics
Oral Sedation
Treatment
Root Planing
Incision & Drainage
Other Procedure
Anaesthesia required (if applicable)
Please Select
General Anaesthesia
Local Anaesthesia
Please list any medications prescribed
Do you have any allergies?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
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
I allow and authorize (Halimatu Musa Hospital) to perform this procedure to me. The doctor explained the nature of the treatment and how it will help me.
I allow (Halimatu Musa Hospital) to administer 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 understand that I am not allowed to eat or drink 4-6 hours before the procedure.
I acknowledge that all information I provided in this form is true and accurate.
Patient/Parent/Guardian Signature
Signed Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: