Declaration Form

Declaration Form
Declaration by dentist

I can confirm that I discussed all treatment management options with the patient, including local anaesthetic only, inhalation, sedation, intravenous sedation and general anaesthetic.

The patient is aware of the differences and has requested treatment with conscious sedation.
Name*

First NameLast Name
Date*

DayMonthYear
Dentist Signature*

Clear
Declaration by patient

I agree that the dentist has discussed the difference between conscious sedation and general anaesthetic, and I have requested treatment with conscious sedation.
Name*

First NameLast Name
Date*

DayMonthYear
Patient Signature*

Clear
Should be Empty: