Dental Treatment Consent Form - Patient Acknowledgement - Read and Consent

Oct 6, 2026

Uploaded by iuabcfuw

Dental Treatment Consent Form for a named patient outlines consent to disclose complete medical and dental history and explains how undisclosed information, past surgeries, current medication, and allergies can create risks. It covers potential drug reactions, latex and medication hazards, needle-stick blood testing, complications related to fillings, crowns, and root canals, and the possibility of failure and extraction. It also addresses gum treatment expectations, extraction or surgery risks, additional specialty care costs, insurance coverage limits, 24-hour cancellation notice, record transfer rules, hygiene appointment timing, and confirmation of reading and consenting to treatment.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

1. Health Information

2. Drugs, Latex and Medicines

3. Needle Stick

4. Fillings, Crowns and Un-anticipated Root Canals

5. Root Canals can fail

6. Porcelain Crowns, Veneers, Bonding and Cosmetic Fillings

7. Gum Treatment and Requesting "Just a Cleaning"

8. Extractions and Surgery

9. Fee for Additional or Specialty Care

10. I agree to pay what Insurance does not cover

11. 24 Hour Notice for Cancellation

12. Requesting Record Transfers or Copies

13. Hygiene Appointments

VIH.TRUONG-MAI,DDS,FAGD DENTAL TREATMENT CONSENT FORM Patient Name: # 1.Health Information l agree to disclose all previous illnesses and medical and dental history(i.e.gum disease).UNDISCLOSED MEDICAL INFORMATION-past surgeries,current medication,allergies are risk factors.I agree to allow the use of my information onlywhere it is necessary to process insurance claims. # 2.Drugs,Latex and Medicines I understand that antibiotics and other medicines can cause allergic reactions and even life-threatening anaphylaxis.Also,someantibiotics interfere with birth-control pills.Latex allergy can cause rashes and itching.Epinephrine increases heart beat and,depending on my health,may be dangerous to me. # 3. Needle Stick If someone is inadvertently stuck with a needle used on me,I consent to have blood drawn for analysis. # 4.Fillings,Crowns and Un-anticipated Root Canals Some teeth may need a root canal even after a simplefilling.Fillings and crowns do take away tooth structure and a percentageof these teeth end up needing a root canal after the filling or crown is done. # 5. Root Canals can fail Root canals can fail and may require additional treatment orlmay end up having the tooth extracted. # 6. Porcelain Crowns,Veneers,Bonding and Cosmetic Fillings Porcelain crowns,veneers,bonding and cosmeticfllings are esthetically pleasing.However,I understand that if they chip orbreak after in use successfully,I am responsible for repairs or remakes.Once a crown,veneer,bonding or filling is placed,Iunderstand the color cannot be changed. # 7.Gum Treatment and Requesting"Just a Cleaning" If I don't floss or if I smoke,I can expect to have deteriorating gum condition.I agree that if I need gum treatment,I will notinsist that I simply get a cleaning(prophylaxis). # 8. Extractions and Surgery Iunderstand that all dental extractions or surgeries carry risks.Some are minor like d dry-socket following an extraction.Some are life-threatening such as post-surgical infection or anaphylaxis. # 9.Fee for Additional or Specialty Care Iunderstand that I may need treatment beyond what was originally planned(a crowned tooth becomes painful and will need aroot canal),or I may be referred to a specialist for additional care(root canal was not successful).Iagree to be financiallyresponsible for the additional or specialty care. # 10.Iagree to pay what Insurance does not cover There are charges beyond what insurance will pay,i.e.nitrous oxide,temporary dentures,tapping off old crowns or bridges,bleaching or cosmetic work.Also,as a service to patients,this office willfile insurance claims on their behalf.I understand thatwhat may be quoted as my portion (co-payment)is only an estimate.Iagree to be financially responsible for what insurancedoes not cover. ## 11.24 Hour Notice for Cancellation I agree to give 24 hour notice for cancellations or pay the broken appointment fee.I understand that leaving a message afterthe office is closed the day (or weekend)before is NOT sufficient notice. # 12.Requesting Record Transfers or Copies Professional courtesies are between dentists.I agree not to requests records until l have a new dentist. [Texas State Law allows the dentist to charge up to $25 for the first 20 pages and additional fees for x-rays] # 13.Hygiene Appointments Ifl am more than 15 minutes late for my cleaning appointment,I will either take my remaining time only or reschedule and paya broken appointment fee. I do not expect guarantees in dental care.Ihave read the above and consent to treatment.

FAQs

What information must the patient disclose before dental treatment?

The patient agrees to disclose all previous illnesses and complete medical and dental history, including gum disease, as undisclosed information can be a risk factor.

What risks and complications does the consent cover for dental procedures?

The form explains risks from medicines and latex, and that fillings, crowns, and root canals may fail, sometimes requiring additional treatment or extraction. Extractions and surgeries also carry risks such as dry-socket, infection, or anaphylaxis.

How are cancellations and additional fees handled?

The patient agrees to provide 24-hour notice or pay the broken appointment fee. It also states the patient is financially responsible for care beyond original planning and for charges not covered by insurance.

Oct 6, 2026

Uploaded by iuabcfuw