Dental Care In Your Home
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Dental Care In Your Home "On-Line" Form Submission
DENTAL TREATMENT CONSENT FORM
Name of Dentist
Signature of Dentist
We make available this generalized dental consent form for your review and signature. Please do not hesitate to ask our dental staff any questions you may have. All dental procedures will be performed by licensed dentists and dental hygienists. Initial/introductory examinations will include a complete health history, x-rays, examination and charting of all existing conditions of the teeth and gums and a complete treatment plan before any operative or preventative care will be done. All procedures will be done in your own home or care facility. Please provide us with your dental insurance information, including the name of the person insured, address of the insurance company and their phone number. We also need your dental insurance ID number and complete social security number.
1. DRUGS AND MEDICATIONS (prescribed and administered by a licensed dentist)
I understand that antibiotics, local anesthesia, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
2. CHANGES IN TREATMENT PLAN
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy or extraction following routine restorative procedures.