All fields marked with * are required. |
*Office Location | |
*Patient's Name: | |
*Birthdate: | |
*I give consent for myself/my child to receive dental treatment deemed necessary by the providers at the Open Door Family Medical Center. These procedures include, but are not limited to; examinations, oral prophylaxes (cleanings), fluoride treatments, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) treatments, extractions, and the use of local anesthetics. I understand that the use of local anesthetics carries a small risk for swelling, bruising, allergic reaction, changes in pain perception, or prolonged anesthesia. This consent shall be considered in effect until rescinded or revoked. | |
*Your Name: | |
*Relationship to Patient: | |
*Date: | |
*Signature: | Please sign in the box below using your mouse, touch screen, or touchpad. Clear Use Most Recent SignatureI accept that this is the legal representation of my signature. |
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This section needs to be completed for children under the age of 18 by a parent or legal guardian ONLY.
I affirm that I am the parent or legal guardian for the above named minor child. If I am unable to accompany my child, I give permission for the individuals named below to escort my child for treatments. |
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If child is over 13, please check one: | |
Signature of parent or legal guardian: | Please sign in the box below using your mouse, touch screen, or touchpad. Clear Use Most Recent SignatureI accept that this is the legal representation of my signature. |
This consent shall be considered in effect until rescinded or revoked. |