Dental Procedure Patient Consent
Patient Name
Date of Birth
Procedure
Dentist Name
Description of Procedure
Risks/Complications Discussed
Alternatives Discussed
Questions/Concerns Addressed
I confirm that I have read and understand the information above. I have had the opportunity to ask questions, which were answered to my satisfaction. I voluntarily consent to the dental procedure described above.
Patient Signature
Dentist Signature
Date
Date