Patient Information
Name: _________________________ Date of Birth: _____________
Address: _______________________ Phone: ___________________
1. Consent for Treatment
- I authorize [Practice Name] to provide dental treatment deemed necessary for my oral health.
- I understand that I will be informed about treatment options, risks, and benefits before procedures.
- I acknowledge that no guarantees have been made regarding treatment outcomes.
2. Financial Agreement
- I understand that payment is due at the time of service.
- I agree to pay all copayments, deductibles, and non-covered services.
- Insurance claims will be submitted on my behalf, but I remain responsible for any unpaid balance.
3. Appointment Policy
- I agree to provide 24-hour notice for appointment cancellations.
- I understand that missed appointments may incur a fee of $__________.
- Three missed appointments may result in dismissal from the practice.
4. Privacy Practices
- I acknowledge receipt of the Notice of Privacy Practices.
- I authorize the release of medical information necessary for treatment and insurance claims.
5. Photography Consent
- I permit dental photographs to be taken for treatment planning and documentation.
- Use for educational or marketing purposes requires separate written consent.
6. Emergency Care
- After-hours emergency contact: [Phone Number]
- Emergency care protocols have been explained and understood.
Signatures
Patient/Guardian: _________________ Date: ____________
Provider: ________________________ Date: ____________
Office Use Only
Staff Witness: ____________________ Date: ____________