General Informed Consent Form - fatemifamilydentistry.com

Fatemi Family Dentistry

Informed Consent for Treatment

Before beginning treatment, I wish to be provided with enough information, in a way I can understand, to make a well-informed decision regarding my proposed treatment. I understand that I may ask any questions I wish...

1. Nature of Recommended Treatment

Recommended Treatment: Reason for Treatment: Intended Benefit: Prognosis / Likelihood of success:

Estimated Visits: Estimated Months: Estimated Cost ($):

2. Alternatives & Risks

Alternative Treatments (or write 'No other options'): Patient Initials: I have had an opportunity to ask questions about these alternatives.

Risks of Recommended Treatment: Patient Initials: I have had an opportunity to ask questions about these risks.

3. Specialty Treatment Acknowledgement

Patient Initials: I understand that this procedure can also be performed by a dental specialist. I elect to have this performed by Dr. Fatemi. Patient Initials: I understand that if unexpected difficulties occur, I may be referred to a specialist and the cost is not included in this quote.

I understand and accept the terms, risks, and financial responsibilities described above. *

Patient's Full Name *

Date of Birth *

Signature Date *