Dental Treatment Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

1. I hereby authorize Dr. _________________ and any associates to perform dental procedures deemed necessary or advisable for my dental care, including:
   • Examination, diagnosis, and treatment planning
   • Dental prophylaxis (cleaning) and oral hygiene instruction
   • X-rays, photographs, and other diagnostic aids
   • Local anesthesia administration
   • Restorative procedures (fillings, crowns, bridges)
   • Oral surgery and tooth extractions
   • Periodontal (gum) treatments

Financial Agreement

1. I understand that payment is due at the time of service
2. I acknowledge responsibility for all charges related to dental treatment
3. Insurance benefits, if any, will be verified and estimated, but are not guaranteed

Acknowledgments

I understand that:

• Dental treatment carries inherent risks and no guarantee of results can be made
• Changes in treatment may be necessary during the course of treatment
• I have the right to ask questions about any aspect of my treatment

Signatures

Patient/Guardian Signature: _________________ Date: _________ Witness: _________________________________ Date: _________

Office Use Only

Dental History Reviewed: □ Yes □ No Medical Alerts: _________________________ Notes: ________________________________