Download Willow Tree Dental, PLLC GENERAL CONSENT FOR DENTAL

Willow Tree Dental, PLLC
GENERAL CONSENT FOR DENTAL TREATMENT
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Patient's Name
DOB
Date
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.
You have the right to be informed about your diagnosis and planned procedure so that you can decide whether to have a procedure or not after
knowing the risks, benefits and alternative options.
Diagnostic & Preventive Services:
I understand the need for and consent to all necessary diagnostic xrays, clinical photography, clinical videography and study
models. I understand and authorize any cleaning of teeth, application of topical fluoride and placement of sealants for myself or
my child whenever deemed appropriate by the dentist. (If there is an estimated out-of-pocket expense to you for any preventive
services, we will attain your approval prior to placement.)
Dental Anesthetics:
I understand the risks as well as the benefits associated with topical anesthetics and local dental anesthetic injections and hereby
consent to their use whenever deemed appropriate by the dentist for any dental procedure including but not limited to xrays,
impressioin, fillings, cleaning including scaling and root planing, crowns, bridges, dentures, and root canal therapy for myself or
my child.
Emergency Care:
Emergency dental care is intended to provide relief of severe pain and infection for individual in acute need. After-hours
emergencies are subject to an additional charge.
Dental Records:
The dental medical record, xrays, photographs, videos, models and other diagnostic aids relating to dental treatment are the
property of Willow Tree Dental, PLLC. You have the right to inspect such materials and to request a copy of your dental medical
records and radiographs. There is a $25 fee for copying or releasing these records. You may have your dental radiographs sent
to another health care provider by signing a Release of Information form.
Drugs and Medications:
I have fully disclosed all medication history truthfully. I understand that antibiotics, pain medications, anesthetics and other
medications can cause allergic reactions, resulting in redness and swelling of tissues, itching, pain, nausea and vomiting or more
severe allergic reactions. I have told the doctor of any known allergies. I know it is important to take any medicines that are
prescribed for me as directed to help minimize potential problems. Certain medications may cause drowsiness and I should not
drive or operate hazardous equipment when using such drugs. If I have a problem, I should get appropriate medical care from
either my doctor or in emergencies by calling 911.
Clinical Photography and Clinical Videography:
I authorize Willow Tree Dental, PLLC to use photographs, radiographs and other diagnostic materials and treatment records for
the purpose of teaching, marketing, research or scientific publication. Such materials may be reproduced, published, printed, used
and distributed. It is specifically understood that in any publication or use, NO PATIENT will be identified by name. NO FULL
FACE OR IDENTIFYING FEATURES WILL BE PUBLISHED WITHOUT THE EXPRESSED WRITTEN CONSENT OF THE
PATIENT OR HIS/HER AGENT FOR EACH ITEM.
Changes in Personal Information and/or Medical History
I understand that it is my responsibility and agree to inform and update Willow Tree Dental, PLLC of any changes in personal
information and medical history. This includes but is not limited to changes in employment, insurance, custody arrangements,
change in residence, phone numbers and email addresses.
Changes in Treatment Plan:
I understand that it may be necessary during treatment to change or add procedures because of conditions discovered during
treatment that were not evident during examination. If so, I will be advised by my doctor.
I understand that my doctor cannot guarantee the results of treatment. I have read and understand the above and give my consent to
recommended treatment under the described terms and conditions. I have given a complete and truthful medical history, including all
medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this
form.
Patient's (or Legal Guardian's) Signature
Date
Doctor's Signature
Date
Witness' Signature
Date