The Loving Dentist - After Hours Care

Informed Consent for Patients with Periodontal Concerns

I, ,consent to be a patient at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following:

  1.  During the course of treatment, I may undergo procedures in all phases of dentistry
    including periodontics (gum treatment and surgery), oral surgery, endodontics (root
    canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant
    dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea
    treatment, oral pathology, pediatric dentistry, and radiography.
  2.  I will provide a thorough and complete medical history, supply a full list of my
    medications with dosages, and consent to my dentist communicating with my other
    medical practitioners to inquire about any aspect of my health history.
  3.  No guarantees can be made about treatment outcomes, restoration longevity, or prognoses.
    I understand that any branch of medicine, including dentistry, can involve unanticipated
  4. . I will pay in full any cost of treatment or insurance copayments according to the office’s
    financial policy. I understand that even if an insurance preestimate is given or a procedure
    has been preapproved, I am responsible for any costs that my insurance does not cover.
  5.  My treatment plan may change at any time and I will do my best to approach my dental
    care with open communication with my dentist, hygienist, and dental office staff.
  6. . I am welcome to ask questions about any aspects of my dental care and will request
    information if I am confused or need more information. I am responsible for clarifying
    any aspects of my treatment that I am unsure about.

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Signed by The Loving Dentist After Hours Care
Signed On: April 4, 2018

The Loving Dentist - After Hours Care
Signature Certificate
Document name: Informed Consent for Patients with Periodontal Concerns
Unique Document ID: 9ac05b6ede9cb4d23a8df9428a081ee243215ee2
Timestamp Audit
April 4, 2018 12:57 pm EDTInformed Consent for Patients with Periodontal Concerns Uploaded by The Loving Walk-In Dental Clinic of Orlando - IP