Dental Informed Consent Form

Dental Informed Consent Form
Maine Oral Health & Wellness offers comprehensive care which may include restorative dentistry including decay arresting treatments, fillings, crowns etc. There may be areas of concern that we can address while providing care during the clinic we are offering. Please complete this form to acknowledge and consent to treatment that we provide beyond dental hygiene services, that will be performed by our Dentist when we return to the clinic location where you or your child was seen previously.
Phone call to discuss treatment that is recommendedTreatment can be performed without a phone call to discuss treatment
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Dental Procedure Details

Please answer these questions thoroughly so that we can provide the best care
Has your child ever had reactions to local anesthetic or dental materials?
Has your child had any illness, hospitalization sickness in the last 10 days?
Are they currently taking any medications?
If yes, then please specify it on the field above.
Do they 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 (Maine Oral Health & Wellness, Dr Barbara Oesterlin) to perform this procedure to me. The doctor explained the nature of the treatment and how it will help me.I allow (Maine Oral Health & Wellness, Dr Barbara Oesterlin) 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 acknowledge that all information I provided in this form is true and accurate.
Patient/Parent/Guardian Signature

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Signed Date

MonthDayYear
Date
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Dental Informed Consent Form

Patient Information

Parent/Guardian Information

Dental Procedure Details

Acknowledgment and Waiver