Patient Form

General Consent for Treatment

Please review and provide consent for routine dental care.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Consent

I consent to a dental examination. *

I consent to dental X-rays if my dentist determines they are needed. *

I consent to routine dental treatment as discussed with my dentist. *

I understand my dentist will discuss treatment options with me and that no specific outcome is guaranteed. *

I understand it is my responsibility to ask questions about my care. *

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.