Dental Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: _________________

Agreement Terms

1. Consent for Treatment

I hereby authorize Dr. _________________ and any associates or assistants of their choosing to perform dental procedures deemed necessary or advisable for my dental care, including but not limited to:

• Comprehensive examination and diagnosis
• Dental cleanings and preventive treatments
• Restorative procedures (fillings, crowns, bridges)
• Local anesthetic administration
• Radiographs (X-rays) as needed
• Emergency dental treatments

2. Treatment Plan Understanding

I understand that:

• The proposed treatment plan will be explained to me
• Alternative treatment options will be discussed
• No guarantee of treatment outcomes can be made
• Treatment plans may need modification based on findings during procedures

3. Financial Agreement

I acknowledge that:

• Payment is due at the time of service
• I am responsible for charges not covered by insurance
• A detailed fee schedule has been provided to me
• Financing options have been explained (if applicable)

4. Risks and Complications

I understand that dental procedures may involve risks, including but not limited to:

• Post-treatment discomfort or sensitivity
• Infection or swelling
• Changes in bite or tooth alignment
• Need for additional treatments

5. Patient Responsibilities

I agree to:

• Provide accurate medical history information
• Follow pre- and post-treatment instructions
• Maintain scheduled appointments
• Notify the office of any complications

Acknowledgment

I have read and understand this agreement. My questions have been answered to my satisfaction.

Patient/Guardian Signature: _________________________ Date: _________________

Dentist Signature: _________________________________ Date: _________________

Witness: _________________________________________ Date: _________________