General Consent Form

Please read and sign the following responsibility and consent statement:

I authorize and request the performance of dental services for myself or my minor child and give my consent to any advisable and necessary dental procedures, medication, anesthetics or analgesics to be administered by the attending dentist or by his supervised staff for diagnostic purposes or dental treatment. You will be informed of planned services before services are rendered.

I understand that I am responsible for any financial obligation incurred for the services provided.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.