General Consent Form - DS Family and Cosmetic Dentistry

General Consent Form
I hereby authorize Dr. Daniel Sluyk to perform the procedure(s) or course(s) of treatment listed below. I understand my dental condition and have discussed all treatment options.
Local Anesthesia
Nitrous Oxide (N20):
Oral Sedation:
Composite Filling:
Enter Tooth Number
Porcelain Crown:
Enter Tooth Number
Permanent Restoration:
Enter Tooth Number
Scaling and Root Planing + Laser Therapy:
Enter Tooth Number
Social Media Release:
I understand the risks associated with the treatment and have discussed these risks with Dr. Daniel Sluyk. The dentist has addressed all questions and concerns I have presented. I understand the expected results of the procedure(s). I understand that these results cannot be guaranteed and may not be achieved. I am aware of my right to waive treatment of any kind and I am aware of the possible consequences of not proceeding with treatment.
Patient Name

First NameLast Name
Patient/Guardian Signature

Clear
Date

MonthDayYear
Witness Name
type witness name here
Should be Empty: