Patient Dental History
I, the undersigned, consent to treatment which is advisable and agreeable to both myself and the dentist with the realization that certain are and infrequent complications may occur. These may include injury to the following:
I understand there can be no guarantees as to any treatment result or cure. I realize that additional Therapeutic procedures may become apparent during treatment and allow the dentist to use his judgment.
Signature of patient / guardian: ____________________________________________ Date: ____________________________________