Informed Consent for Dental Restoration without Parent or Guardian

Informed Consent for Dental Restoration without Parent or Guardian

Please review and complete this form to provide consent for dental restoration procedures performed without a parent or guardian present.
Patient Full Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Appointment Date

MonthDayYear
Date
AppointmentTime

Hour Minutes

AM/PM Option
Consenting Parent/Guardian Contact Name*

First NameLast Name
Consenting Parent/Guardian Contact Phone Number*
Please enter a valid phone number.
I accept the benefits and risks of the dental restoration and understand that the risks include, but are not limited to the following:
- Pain and Sensitivity lasting between 2-6 weeks
- Pro-longed Numbness
I understand that payment is due at the time services are rendered and have made arrangements to pay before the appointment or I am sending payment with my dependent.

All my questions have been answered in full and understand the risks, benefits, options, and alternatives to treatment. If I have additional questions or concerns, I am aware that I must contact our office for further clarification as needed.
By signing below, I confirm that I have read and understood the information regarding the dental restoration procedure. I hereby give my informed consent for Dr. Christopher Cansler to perform the necessary dental restoration in the absence of a parent or guardian. I acknowledge the potential risks and benefits, and authorize the dental provider to proceed as needed for the patient's health and safety.
Signature of Consenting Individual (Patient or Authorized Representative)*

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