General Consent Form - Richland Dentistry, Plc (Page 3 of 3) in pdf

General Consent Form - Richland Dentistry, Plc Page 3

I hereby authorize the dental staff of Richland Dentistry to proceed with and perform the

dental restorations and treatments as explained to me. I understand that this is only an

estimate and subject to modification depending on unforeseen circumstances that may

arise during the course of treatment. I understand that regardless of any dental insurance

coverage I may have, I am responsible for payment of dental fees. I agree to pay any

attorney's fees, collection fees, or court costs that may be incurred to satisfy this

obligation.

I understand that dentistry is not an exact science and that, therefore, reputable

practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance

has been made by anyone regarding the dental treatment that I have requested and

authorized. I have had the opportunity to read this form and ask questions. My questions

have been answered to my satisfaction. I consent to allow Richland Dentistry to take any

necessary x-rays and perform an examination on me today.

Patient or Parent/Guardian

Signature: _________________________________________________

Date: ___________

Doctor

Signature: _________________________________________________

Date: ___________

Witness

Signature: _________________________________________________

Date: _________

General Consent Form - Richland Dentistry, Plc Page 3