General Consent for Treatment
Provide your details, review the consent information, and sign to authorize dental care.
Synergy Dental Solutions · Dr. Angie Tenholder, DMD, FAACP, DABCDSM, FAGD · 1000 Eleven South, Suite 3F, Columbia, IL 62236 · Phone (618) 281-9729 · Fax (618) 281-9734 · WeCare@WeAreSynergy.com
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Thank you for choosing Synergy Dental Solutions. This form explains the everyday dental care we provide and asks for your permission to provide it. Please read it, ask us anything, and sign at the bottom.
1. Examination and imaging. I consent to a dental examination by Dr. Angela Tenholder and her team, including x-rays and other imaging the dentist recommends to understand my oral health.
2. Cleanings and routine care. I consent to dental cleanings and to routine treatment that the dentist recommends and that I agree to.
3. Treatment beyond routine care. Before any treatment beyond routine care, the dentist will explain my options, the expected benefits, the possible risks, and the alternatives, including choosing no treatment. I may be asked to sign a separate consent for that treatment. Specialized therapies, such as laser therapies and NeuralFORM Dental Device Therapies, have their own separate consent forms.
4. Local anesthesia (numbing medicine). Some care uses a local anesthetic to numb the area being treated. Common effects are temporary and can include: numbness of the lip, cheek, tongue or chin for a few hours; soreness or a small bruise where the medicine was given; a brief feeling of a faster heartbeat. Please take care not to bite or chew numb lips, cheeks or tongue until feeling returns, and watch children closely. Rarely, numbness lasts longer than expected; if it does, call us at (618) 281-9729.
5. No guarantee of results. We will always do our best for you. I understand that dentistry is not an exact science, and that no specific result can be guaranteed.
6. My right to ask and to decide. I may ask questions at any time. I may refuse any treatment, or ask to stop treatment at any time. If I stop partway, the dentist will explain what that may mean for my care.
7. Children. If the patient is under 18, a parent or legal guardian gives this consent on the child's behalf and signs below.
8. How long this consent lasts. This consent stays in effect until I withdraw it in writing.
By signing below, I confirm that I have read this form, my questions have been answered, and I give my consent.
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I give my consent
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