Patient Consent Form

Patient's Info

Patient's Contact

Emergency Contact Information

Please provide the contact information for an emergency person we can contact. Please try to choose someone not using your family home phone number.

Patient Consent

This is to certify that I, the undersigned consent to:

• The performing of dental and oral surgery procedures that have been agreed upon.
• The use of local anesthetic (and adjunctive analgesic/sedative agents) as agreed upon.
• The taking of x-rays and photographs before, during and after treatment and the use of same by Doctor for educational purposes and scientific papers.

I understand that I am responsible for fees associated with dental procedures and that payment is required on the day treatment is rendered. There will be no charge for missed appointments provided 48 hours notice is given. Charges are assessed at $50.00 per half hour of appointment time.