Clone of Informed Consent for Oral Surgery

Final Delivery Consent
I approve the color, shape, feel and overall appearance of my:
If you selected "Other" please explain here:
I approve the appearance of my restoration including color, shape, and feel.

I understand that after final delivery, any replacement/remake requests will require additional fees at my expense and are not eligible for a refund.

I give King Family Dental Care, P.A. permission for final delivery.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient or Parent / Guardian Full Name

First NameLast Name
Patient or Parent/Guardian Signature
Attending Dentist Full Name

First NameLast Name
Attending Dentist Signature
Witness Full Name

First NameLast Name
Witness Signature
Should be Empty:

Final Delivery Consent