Dental Cleaning Consent Form

Full Name: Date of Birth: Phone Number:

I acknowledge that my dentist has explained the nature, purpose, benefits, and possible risks and alternatives of dental cleaning (prophylaxis). I understand that although rare, potential risks may include irritation, bleeding, tooth sensitivity, infection, or gum discomfort.

I have had the opportunity to ask questions and they were answered to my satisfaction. I consent to proceed with the dental cleaning procedure. Please list any allergies, medical conditions, or medications: Contact Name: Contact Phone: Date: