Informed Consent for Dental Treatment
- I hereby authorize Shelby Pines Family Dentistry to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of your dental needs.
- Upon such diagnosis, I authorize Shelby Pines Family Dentistry to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
- I hereby authorize Shelby Pines Family Dentistry to administer anesthetic, sedative and or nitrous oxide (laughing gas) as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications associated with this.
- I agree to be responsible for payment of all services rendered on my behalf or my dependents behalf. I understand that payment is due at the time of service unless other payment arrange-ments have been made. In the event that payment is not made I understand there may be a late charge added to my account. I also agree to pay for all collection costs if additional collection is required.
It is very important that you provide your dentist with accurate information before, during and after treat-ment. It is equally important that you follow your dentists advice and recommendations regarding medica-tion, pre and post treatment instruction, referrals to other dentists or specialist, and return for scheduled appointment. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.
The patient is a very important part of the treatment team. In addition to complying with the instructions given to you by this oce, it is important to report any problems or complications you experience so they can be assessed by your dentist.
In accordance with the Health Insurance Portability and Accountability Act (HIPAA), this information will tell you about the ways in which we may use and disclose medical/dental information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your personal, identiable health and medical information.
**Please feel free to review the “PRIVACY POLICIES” booklet our oce follows. The booklet will be located in the reception area next to the check in desk.
*By typing your name in the signature box above, you are certifying that the information included in this form is true to the best of your knowledge. Typing your full name in the signature above is the legal equivalent of your written signature, and will stand as such in all legal matters.
*If patient representative signs above, please describe the relationship to the patient:
Shelby Pines Cosmetic & Family Dentistry
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operations?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet
Do you use controlled substances?
Women: Are you
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Cold Sores/Fever Blisters
Congenital Heart Disorder
Have you ever had any serious illness not listed above?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.