Cosmetic Dentistry Consent Form

Patient Name Date of Birth Phone Number Email Address Procedure(s) to be Performed

Consent

I acknowledge that I have discussed the nature and purpose of the cosmetic dental procedure(s) with my dentist. I understand the potential risks, complications, and alternative options to the treatment, as well as the expected results and limitations. I have had the opportunity to ask questions regarding the procedure(s) and understand that results may vary.

I consent to the recommended cosmetic dental treatment and authorize my dentist and healthcare team to perform the procedures as described.

Patient Signature Date

Provider/Witness Signature Date