Dental Treatment Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: ___________________ Date: ___________________

Purpose of Treatment

I hereby authorize Dr. _________________ and any associates to perform the following dental treatment:

• Diagnostic procedures and dental prophylaxis
• Restorative procedures (fillings, crowns, bridges)
• Local anesthetic administration

Understanding of Treatment

I understand that:

1. The purpose of the treatment has been explained to me
2. Alternative treatment options have been discussed
3. The risks and benefits have been clearly communicated

Potential Risks

• Bleeding, swelling, and temporary discomfort
• Infection requiring additional treatment
• Nerve injury resulting in temporary or permanent numbness
• Changes in bite or TMJ discomfort
• Allergic reactions to dental materials

Financial Agreement

I understand that:

• Payment is due at time of service
• Insurance coverage may vary
• I am responsible for any amounts not covered by insurance

Consent Declaration

I certify that I have read and fully understand this consent form. I have been given the opportunity to ask questions, and all my questions have been answered satisfactorily.

Patient/Guardian Signature Date

Dentist Signature Date

Witness Signature Date