Specialty Dental Procedure Consent Form
Patient Information
Full Name
Date of Birth
Phone Number
Address
Procedure Information
Procedure Name
Description of Procedure
Risks & Alternatives
Risks / Complications
Alternatives
Consent Confirmation
I have read and understand the information above.
I have had the opportunity to ask questions.
I voluntarily give my consent for this procedure.
Patient Signature
Date
Witness / Dental Staff Signature
Date