VISTA DENTAL STUDIO

Name of Patient:-

Age:-

Gender

Address:-

Profession:-

Contact no:-

Email:-

Emergency contact number :-

Reason for visit :-

Referred by:-

Blood group:-

ANY KNOWN MEDICAL CONDITION

GENERAL CONSENT

I agree TO GIVE MY CONSENT TO DR. NIKHIL SARAN BDS MDS FICOI, VISTA DENTAL STUDIO, Hyderabad and/or the Dental Surgeons & Consultants in charge to proceed with the diagnosis and treatment plan and the cost estimation. I accept the risks and its complications if any, In hope of obtaining the desired benefits from the procedures, which may include X-ray, use of anaesthetic agents, blood and blood products, medications. I understand that Dental Materials, Instruments, Equipment’s, Antibiotics, Analgesics, Anaesthetic and other Medications can cause Allergic reactions and may cause redness, and swelling of tissues, in severe cases may exhibit as pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). I take full responsibility to bear the cost of the treatment which will be suggested to me. I do understand the complexity of the dental procedures which sometimes require to change or add procedures because of conditions found while working on my teeth apart from the chief complain I came with. I also understand realise that it is my duty to ask relevant questions about the diagnosis & procedures to be carried out prior to treatment along with the risks associated, and the possible alternative treatments available for my condition. I will agree to the observation and photography in the operating room during the procedures in order to advance dental education.

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