Treatment Consent Form

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Parent/Guardian Consent:

  • The dental practitioner has explained the treatment required and any associated risks, including any risks associated with not undertaking the proposed treatment.
  • I agree to being referred to another dentist/specialist - if required. I understand that all costs incurred from referred treatment are additional to this treatment plan and will be at my own expense.
  • I have been given the opportunity to discuss and clarify any concerns regarding treatment with the dental practitioner.
  • I understand that the result of the treatment cannot be guaranteed and should it become necessary to alter the treatment plan I will be advised of the changes and amendments to the cost.
  • I understand that I have the right to change my mind at any time before the treatment is undertaken, including after I have signed this form. I understand that I must inform the clinic if this occurs.
  • I agree to undergo the treatment as documented on this form. I also consent to such further procedures as may in the opinion of the treating clinician, be found to be necessary during the course of care.
  • I understand that I am responsible for the fees as estimated on this form. These fees are effective at the date of printing and are subject to revisions every 3 months.
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