Dental Treatment Consent Form

* Required information

Patient's Name*:

1. I hereby authorize Drs. Nguyen and associates to perform routine dental care and/or any other therapeutic procedure that their judgment may dictate to be advisable for the patient well-being.

2. If in Drs. Nguyen's and associates's opinion that patient names above requires the services of a specialist, he/she agrees to accept the referral and will be responsible for any expense that may be incurred.

3. Drug and Medication: I understand that antibiotics and analgesic, local anesthetic , etc. can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). If in Drs. Nguyen's and associates's option, further observation of the patient is indicated after an anesthetic or procedure, the patient agrees to be transported by ambulance at his/ her personal expense and to be admitted for observation and any necessary treatment.

4. Changes in treatment plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common, but not limited to, is the Root Canal Therapy following routine restorative procedure. I give my permission to Drs. Nguyen and associates to make any/all changes and additions as necessary.

5. I acknowledge that no guarantee or assurance has been made by anyone at Excellent Dental Care Center and EDC regarding the dental treatment which i have requested and authorized. I certify that i have read this consent, or that it has been read to me, and I consent to the proposed treatment.

Your Name*:

Last Name*:


Patient/Legal Guardian's Signature*
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