Self Assessment
Choose Consent Form
dental consent form
File Number:
DENTAL CONSENT FORM
• I have fully and correctly informed about all my Medical History
• I assure I will always update my Medical History on my future visits and I understand that withholding information or providing misinformation may result in contraindication and/or irritation to any dental treatments received.
• I have had an opportunity to have my questions answered regarding the proposed procedure. I therefore give consent to having my advised dental procedure.
• I acknowledge that I have read and understood all the information provided and feel free that the doctor has adequately informed me regarding that risks of the treatment, alternative methods of the treatments as well as risk of unsuccessful treatment
• I hereby authorize and direct Medical Village dental doctor to perform the treatments and assume full responsibility thereof.
• I agreed about the price and the VAT will be added into it for cosmetic treatment.
• There are no refunds/transferable for services rendered.
• The treatment I receive here are voluntary and I release this institution from liability and assume full responsibility thereof.
Patient Name
Patient Signature
Date
VENEERS CONSENT FORM
I agree:
1. Price
2. Units of veneers
3. Tooth Ceramic Color
4. Cement Color
Doctor explained clearly that I need to drill my teeth to get a better result and I have authorized doctor to perform accordingly.
I agree to come regularly for checkup of my teeth at least three (3) times a year otherwise the clinic is not responsible for warranty.
Patient Name
Patient Signature
Date
Notes:
Patient Signature
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