Oral Surgery Patient-Provider Agreement and Consent

1. PARTIES

This agreement is made between:

• Provider: [Practice Name], [Address]
• Patient: [Patient Full Name], [Patient Address]

2. SCOPE OF SERVICES

Planned Procedure(s)

• Primary procedure: [Procedure Name]
• Additional procedures (if applicable): [List Additional Procedures]
• Surgical site(s): [Specify Location]

3. FINANCIAL RESPONSIBILITIES

Payment Terms

• Estimated total cost: $[Amount]
• Required deposit: $[Amount]
• Payment schedule: [Details]
• Insurance coverage: [Details]

4. PATIENT ACKNOWLEDGMENTS

I, the undersigned patient, acknowledge and agree to the following:

Pre-Operative Responsibilities

• Providing accurate medical history
• Following pre-operative instructions
• Arranging transportation post-procedure
• Fasting requirements: [Specify Hours]

Post-Operative Care

• Following prescribed medication schedule
• Attending follow-up appointments
• Adhering to dietary restrictions
• Reporting complications promptly

5. INFORMED CONSENT

I understand:

• The nature of the procedure(s)
• Potential risks and complications
• Alternative treatment options
• Expected recovery timeline

6. SIGNATURES

Patient Signature: _______________ Date: _______________

Provider Signature: ______________ Date: _______________

Witness Signature: ______________ Date: _______________

7. EMERGENCY CONTACTS

Primary Contact: [Name, Relationship, Phone] Secondary Contact: [Name, Relationship, Phone]