Consent for Dental Treatment

I, the undersigned, hereby give my consent for the dental procedures that have been explained to me by my dentist, including but not limited to diagnostic tests, examinations, preventive services, and necessary treatments. I understand that the treatment plan may involve various procedures to restore or maintain my oral health.

The treatments may include, but are not limited to, fillings, extractions, crowns, root canals, cleaning, X-rays, and other dental procedures. I understand that all treatments, including those that may be necessary in the future, will be performed under the guidance of the dentist and their staff.

Acknowledgement of Risks

I understand that any medical or dental treatment carries potential risks, including but not limited to infection, pain, bleeding, allergic reactions, and the need for additional treatments or procedures. I also acknowledge that unforeseen complications may arise during treatment.

Right to Withdraw Consent

I understand that I have the right to withdraw my consent at any time before or during treatment, and this will not affect my future access to care.

Consent

I have read and understood the above information. I voluntarily consent to receive dental treatment as described above, and I authorize the dental professionals involved to proceed with the necessary treatment.

Signature of Patient

Date

Signature of Guardian (if applicable)

Date

HIPAA Privacy Notice Acknowledgment

Patient Name

Date of Birth

Phone:

I acknowledge that I have received and reviewed the Notice of Privacy Practices for Smart Choice Dental LLC and understand how my health information will be used and protected.

Patient Signature

Date

If unable to sign:

Reason

Rep. Signature

Relationship

Office Use Only

Refusal to sign

Reason

Staff

Date

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the results of tests, treatment plans, procedures and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I authorize SMART CHOICE DENTAL LLC to release my records and any Information requested to the following individuals.

Name

Relation to Patient

Name

Relation to Patient

Name

Relation to Patient

Name

Relation to Patient

Authorization Regarding Messages (please check all that apply)

I authorize you to leave a detailed message on my home or cell number regarding appointments

I authorize you to leave a detailed message on my·home or cell number regarding medical treatment, care, test results or financial information

I authorize you to leave a message with anyone who answers the phone

Messages may only be left with

Patient Name (PLEASE PRINT}

Date

Patient Signature

"By providing a telephone number and submitting this form, you consent to receive SMS text messages from SMART CHOICE DENTAL LLC about our services. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging and HELP for assistance or call (239) 331-5937. Please see our Privacy Policy at https://www.smartchoicedental.net/"