By signing this Consent Form (or by making payment on the associated invoice, which constitutes electronic agreement and signature for all purposes), I, the undersigned Responsible Party (including as Power of Attorney or guardian for the patient), hereby provide my full and informed acknowledgment, understanding, and consent to all terms, conditions, and provisions outlined in this document. This includes but is not limited to: 1. Responsible Party Consent, 2. Treatment Consent, 3. Financial Consent, 4. Medical History Consent, 5. HIPAA Consent, 6. Consent for Professional House Call Fee, 7. Informed Consent for General Dental Procedures, and 8. Final Acknowledgments and Sign-Off.
1. Responsible Party Consent
I confirm I have legal authority (e.g., as Power of Attorney or guardian) and have provided or will provide supporting documentation if required.
In this consent form, “I” or “my” (or the like) refers to the patient if signing for themselves, or to the legal guardian / Power of Attorney / Responsible Party signing on behalf of the patient.
2. Treatment Consent
Once the consent is signed (or electronically signed and agreed to via this form), an invoice will be sent for the anticipated procedures. Upon payment of the invoice, the patient will be treated at the earliest mutual convenience of the patient, responsible party, and dentist, as discussed verbally.
I understand dental treatment is being provided in a non-clinical setting without immediate access to emergency equipment or personnel. In the event of a medical emergency, 911 will be called and treatment transferred to emergency responders.
I understand and agree that if the originally scheduled dentist is unavailable due to illness, emergency, or any other reason, another qualified, licensed dentist associated with or contracted by Colorado Concierge Dentistry may perform the scheduled treatment. I consent to treatment by such substitute dentist under the same terms and conditions outlined in this agreement.
3. Financial Consent
I understand that I am financially responsible for any costs of the dental service. By signing on behalf of this patient, I acknowledge that I, the responsible party, am taking responsibility for full payment on the account in a timely manner. I acknowledge that finance charges for overdue balances may be assessed, as well as fees associated with collection of debt.
Colorado Concierge Dentistry is a fee-for-service practice and does not bill insurance.
Payment for anticipated and discussed procedures, which have been outlined in the invoice, must be made ahead of treatment.
Any additional procedures deemed needed will be discussed verbally prior to completion and associated invoice will be sent before or following treatment, based on the discretion of Colorado Concierge Dentistry.
I agree to reimburse Colorado Concierge Dentistry for any equipment, instruments, or materials lost, stolen, or damaged at the treatment location.
4. Medical History Consent
I understand that any medical history provided by the facility (if any), submitted through the intake form, or otherwise supplied to Colorado Concierge Dentistry (including by email to Info@ColoradoConciergeDentistry.com) will be relied upon for treatment planning and care. I confirm that all known medical conditions, allergies, medications, and other health concerns have already been disclosed on the previous page(s) or in prior communications.
If any additional or updated medical information exists, I agree to immediately email Info@ColoradoConciergeDentistry.com before treatment begins. If no such additional information is received prior to treatment, it is acknowledged and understood that the dentist will proceed based solely on the information already provided and will not be aware of any undisclosed conditions, allergies, medications, or concerns.
5. HIPAA Consent
This serves as the HIPAA (Health Insurance Portability and Accountability Act) authorization and acknowledgment for the patient named on the invoice.
I authorize disclosure of the patient's protected health information to the following persons or entities for purposes of treatment, payment, and operations:
• The patient
• The recipient of the invoice
• The Power of Attorney / Responsible Party
• The facility (including staff, administrators, and associated medical personnel)
• Any partnering dental offices
If there are additional persons who may be informed, please email name and phone number to Info@ColoradoConciergeDentistry.com.
The U.S. Department of Health and Human Services (HHS) enforces federal privacy regulations commonly known as the HIPAA Privacy Rule (HIPAA). HIPAA requires most doctors, nurses, pharmacies, nursing homes, and other health care providers to protect the privacy of my health information.
Notice of Privacy Practices detailing use/disclosure of protected health information (PHI), my rights (e.g., access, amendment, restrictions), and our duties is available upon request.
I have been advised of my privacy rights as provided by the Health Insurance Portability and Accountability Act of 1996.
I acknowledge that I have received (or have been offered and declined) a copy of Colorado Concierge Dentistry’s Notice of Privacy Practices that describes how my protected health information may be used and disclosed, my individual rights under HIPAA, and the practice’s legal duties with respect to my protected health information.
6. Consent for Professional House Call Fee
If treatment cannot be performed for any reason, including but not limited to the patient refusing or being unable to proceed with treatment on the day of the appointment, the appointment being canceled or rescheduled without timely notice (less than 24 hours in advance), the patient not being present at the agreed-upon location, the patient not being available or ready within 20 minutes of the scheduled appointment time or the dentist’s arrival, the location not being suitable for performing dental treatment (e.g., inadequate space, lighting, access to water or electricity, excessive clutter, or other conditions that prevent safe and effective care), or the dentist or team determining, in their sole professional judgment, that the environment presents a safety risk to the provider, staff, or patient (including but not limited to the presence of animals that cannot be adequately secured, threatening individuals, unsafe structures, or any other hazardous conditions), or the patient or any person at the location is actively ill with a contagious disease (e.g., flu, COVID-19, RSV, norovirus, etc.) or exhibits symptoms of contagious illness (fever, vomiting, uncontrolled coughing, etc.), or the patient is visibly intoxicated, under the influence of impairing substances (legal or illegal), or in an altered mental state that, in the sole professional judgment of the dentist or team, prevents the safe provision of dental care or the ability to obtain valid ongoing consent, then the full Professional House Call Fee will be charged and is non-refundable. Additionally, at the sole discretion of Colorado Concierge Dentistry, other procedural or related charges may also apply, as the appointment time and travel have been exclusively reserved.
I understand that in cases of required check-ups or post-treatment issues, additional house calls may incur separate fees.
7. Informed Consent for General Dental Procedures
I have the right to accept or reject dental treatment recommended by the dentist. This form is intended to provide me with an overview of potential risks and complications. Prior to consenting to treatment, I should carefully consider the anticipated benefits, commonly known risks and complications of the recommended procedure, alternative treatments or the option of no treatment.
During the course of treatment the following care may be provided:
• EXAMINATIONS: Radiographs may be required to complete my examination, diagnosis and treatment plan.
• PHOTOGRAPHS, X-RAYS, AND RECORDS: I consent to the taking of photographs, radiographs, videos, or other records for diagnosis, treatment planning, and dental records. These may be shared with partnering offices or specialists as needed for care.
• DENTAL PROPHYLAXIS (CLEANING): A routine dental prophylaxis involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal disease.
• ANESTHESIA: I understand risks of local anesthesia or sedatives include allergic reactions, nerve injury, bruising, prolonged numbness, or infection.
• PERIODONTAL TREATMENT: Periodontal disease is an infection causing gum inflammation and/or bone loss that can lead to tooth loss. Further treatment may be necessary beginning with a periodontal exam.
• RESTORATIVE (FILLINGS): A restoration may be required to restore a tooth due to decay or unsupported tooth structure. This may lead to root canal and/or crown. Sensitivity is a common effect of a newly placed restoration.
• CROWNS, BRIDGES and VENEERS: These types of restorations may be required when tooth loss due to decay or fracture is too extensive for a routine restoration. In some cases, crowns, bridges and veneer procedures may result in the need for root canal treatment.
• DENTURES - COMPLETE OR PARTIAL: Full or partial dentures are artificial, constructed of plastic, metal and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I understand that dentures may require relining and the cost for this procedure is not included in the initial denture fee and I am responsible for any cost.
• ENDODONTIC TREATMENT (ROOT CANAL): I understand that following any restorative dental treatment that my tooth/teeth may become infected and require root canal treatment or possible extraction.
• EXTRACTIONS AND REMOVAL OF TEETH: Tooth removal (extraction) may be needed for severe decay, infection, fracture, crowding, or other conditions when alternatives (e.g., root canal therapy, crowns, periodontal surgery) are not viable or have been explained to me as options. Risks involved in having teeth removed include pain, swelling, bleeding, spread of infection, dry socket, nerve injury, or damage to adjacent structures. I authorize the dentist to perform extractions and remove the tooth/teeth as necessary. I understand that the patient may need further treatment by a specialist if required, and that I am responsible for any associated costs. Alternatives and potential complications have been explained to me, post-care instructions will be provided and must be followed, and referral to a specialist may be required.
• CHANGES IN MY TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on teeth.
• TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD): Symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment when the mouth is held in the open position.
• INFECTION RISKS: I acknowledge risks of procedures in a non-clinical setting and consent to the dentist's infection control protocols (e.g., PPE, sanitation).
• MEDICATIONS: I consent to prescribed medications (e.g., antibiotics, pain relievers) and understand potential side effects, interactions, or allergies.
• REFERRALS AND EMERGENCIES: If complications arise requiring specialist care (e.g., oral surgeon), I am responsible for arranging and paying for it. In emergencies, seek immediate care at the nearest facility / emergency room and notify the dentist.
8. Final Acknowledgments and Sign-Off
This agreement is governed by the laws of the State of Colorado.
In the unlikely event that any concern or dispute arises regarding the care provided or fees charged, I agree to contact Colorado Concierge Dentistry directly at Info@ColoradoConciergeDentistry.com or by phone so that we may attempt in good faith to resolve the matter informally before either party pursues mediation, arbitration, or any other legal remedy.
Any disputes shall be resolved through mediation or binding arbitration in Denver County, Colorado, under the rules of the American Arbitration Association, with each party responsible for its own costs and fees, before pursuing litigation.
I have had the opportunity to ask questions and understand the risks, benefits, and alternatives. No guarantees have been made about outcomes.
I understand that I may revoke this consent in writing at any time, except to the extent that action has already been taken based on it. Revocation should be emailed to Info@ColoradoConciergeDentistry.com. Revocation does not affect actions already taken or information already disclosed under this consent.
I agree to all sections, including 1. Responsible Party Consent, 2. Treatment Consent, 3. Financial Consent, 4. Medical History Consent, 5. HIPAA Consent, 6. Consent for Professional House Call Fee, 7. Informed Consent for General Dental Procedures, and 8. Final Acknowledgments and Sign-Off.
I acknowledge reading and understanding this form.