Patient Name

Your Email (required)

Informed Consent Form for General Dental Procedures

You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:
1. Pain, swelling, and discomfort after treatment
2. Infection in need of medication, follow-up procedures, or other treatment
3. Temporary, or on rare occasion, permanent numbness, pain, tingling, or altered sensation of the lip, face, chin, gums, and tongue, along with possible loss of taste
4. Damage to adjacent teeth, restorations, or gums
5. Possible deterioration of your condition which may result in tooth loss
6. The need for replacement of restorations, implants, or other appliances in the future
7. An altered bite in need of adjustment
8. Possible injury to the jaw joint and related structures requiring follow-up care and treatment or consultation by a dental specialist
9. A root tip, bone fragment, or piece of a dental instrument may be left in your body and may have to be removed at a later time if symptoms develop
10. Jaw fracture
11. If upper teeth are treated, there is a chance of sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment
12. Allergic reaction to anesthetic or medication
13. Need for follow-up care and treatment, including surgery

It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre- and post-treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary.

The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if you dentist prescribes, or if you are taking, antibiotics.

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

Dr. Morin often takes photos to better explain certain aspects of your existing dental health or planned treatment to you. We request your permission to show these photographs to better explain treatment options to other patients (as you will be shown photos for the same reason). And since he has a reputation as an expert on Cosmetic Dentistry, he also makes presentations to other dentists and professionals where the photos are invaluable in explaining the latest techniques and the results that can be achieved when done precisely. We also request your permission to post photographs of you and your smile on our website.

I hereby authorize HI-TECH Family Dentistry to administer dental treatment and local anesthetic and/or nitrous oxide (laughing gas) and to perform procedures deemed necessary in the diagnosis and dental treatment of the above named patient. I further authorize HI-TECH Family Dentistry or anyone acting on its behalf to release information acquired in the course of the patient examination or treatment. I also consent to and authorize HI-TECH Family Dentistry to process insurance claims, communicate with insurers or other third parties, including my employer, who may have information pertaining to the payment of services. I hereby assign HI-TECH Family Dentistry benefits which are due or are to become due as a result of dental services rendered to the above mentioned patient. I hereby authorize that payments be made directly to HI-TECH Family Dentistry.

I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance, for myself or the above named patient, unless other financial arrangements are approved. I also agree to pay for all costs of collection, including attorney fees and court costs, should additional means of collection be required.

E-Signature

Date

Patient Name

Your Email (required)

Acknowledgement of Receipt of this Privacy Practices Notice

I acknowledge that I have received and/or reviewed the notice of the Privacy practices of this office. I am aware that I may receive a paper copy of this notice if I request it. In addition, I acknowledge that this notice of the practice's Privacy Practices is posted in the office where I can review it if desired.

Patient or Parent

Date

Patient Name

Your Email (required)

Birth Date

Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now? YesNo
If yes, who is your physician:

Have you ever been hospitalized or had a major operation? YesNo
If yes, please explain:

Have you ever had a serious head or neck injury? YesNo
If yes, please explain:

Are you taking any medications, pills, or drugs? YesNo
If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux? YesNo
If yes, please explain:

Have you ever taken Fosamax, Boniva, Actonel, or other medications containing biophosphates? YesNo
If yes, please explain:

Are you on a special diet? YesNo

Do you use tobacco? YesNo

Women: Are you... Pregnant/Trying to get pregnantNursingTaking oral contraceptives

Are you allergic to any of the following?
AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther
If other, please explain:

Do you use controlled substances? YesNo
If yes, please explain:

Do you have, or have you had, any of the following?

AIDS/HIV Positive YesNo
Alzheimer's Disease YesNo
Anaphylaxis YesNo
Anemia YesNo
Angina YesNo
Arthritis/Gout YesNo
Artificial Heart Valve YesNo
Artificial Joint YesNo
Asthma YesNo
Blood Disease YesNo
Blood Transfusion YesNo
Breathing Problems YesNo
Bruise Easily YesNo
Cancer YesNo
Chemotherapy YesNo
Chest Pains YesNo
Cold Sores/Fever Blisters YesNo
Congenital Heart Disorder YesNo
Convulsions YesNo
Cortisone Medicine YesNo
Diabetes YesNo
Drug Addiction YesNo
Easily Winded YesNo
Emphysema YesNo
Epilepsy or Seizures YesNo
Excessive Bleeding YesNo
Excessive Thirst YesNo
Fainting Spells/Dizziness YesNo
Frequent Cough YesNo
Frequent Diarrhea YesNo
Frequent Headaches YesNo
Genital Herpes YesNo
Glaucoma YesNo
Hay Fever YesNo
Heart Attack/Failure YesNo
Heart Murmur YesNo
Heart Pacemaker YesNo
Heart Trouble/Disease YesNo

Hemophilia YesNo
Hepatitis A YesNo
Hepatitis B or C YesNo
Herpes YesNo
High Blood Pressure YesNo
High Cholesterol YesNo
Hives or Rash YesNo
Hypoglycemia YesNo
Irregular Heartbeat YesNo
Kidney Problems YesNo
Leukemia YesNo
Liver Disease YesNo
Low Blood Pressure YesNo
Lung Disease YesNo
Mitral Valve Prolapse YesNo
Osteoporosis YesNo
Pain in Jaw Joints YesNo
Parathyroid Disease YesNo
Psychiatric Care YesNo
Radiation Treatments YesNo
Recent Weight Loss YesNo
Renal Dialysis YesNo
Rheumatic Fever YesNo
Rheumatism YesNo
Scarlet Fever YesNo
Shingles YesNo
Sickle Cell Disease YesNo
Sinus Trouble YesNo
Spina Bifida YesNo
Stomach/Intestinal Disease YesNo
Stroke YesNo
Swelling of Limbs YesNo
Thyroid Disease YesNo
Tonsilitis YesNo
Tuberculosis YesNo
Tumors or Growths YesNo
Ulcers YesNo
Venereal Disease YesNo
Yellow Jaundice YesNo

Have you ever had any serious illness not listed? YesNo
If yes, please explain:

Comments:

By entering my name in the field below, I agree that, to the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

E-Signature of Patient, Parent or Guardian:

Date:

Patient Name

Your Email (required)

What dental care would you like us to provide today?

When was your last dental visit?

YesNo - Are you having PAIN, SWELLING, or SORE SPOTS at this time?
YesNo - Do your GUMS BLEED?
YesNo - Have you had GUM TREATMENTS?
YesNo - If you SNORE, would you like an oral device to help you?
YesNo - Do you have BAD BREATH?
YesNo - Is this your FIRST VISIT to any dentist?
YesNo - Have you had any complications with dental treatment?
YesNo - Have you been treated for TMJ (Temporomandibular joint) problems?
YesNo - Do you have REMOVABLE UPPER dentures or partials?
YesNo - Do you have REMOVABLE LOWER dentures or partials?
YesNo - Do you have a FEAR of dentistry?
YesNo - Do you like your SMILE?
YesNo - Have you had a complete set of X-RAYS taken in the past 3 years?
YesNo - Is your WATER FLUORIDATED?
YesNo - Have you visited our website at SouthfieldMI.dentist?

In order for us to provide you with the best quality of care, we like to get to know you better. As a provider, all of the following are important to us, however, we would like to know which is most important to you.

When considering having treatment done, which of the following would be a concern for you?

What would you say would be the most important quality for you in a relationship with your dentist?

Patient Name

Address

Home Phone

Work Phone

Birthdate

Sex

Social Security Number

Driver's License Number

Your Email (required)

How did you hear about our office?

In Case of Emergency - contact name and phone number

Financially Responsible Person

Address

Home Phone

Work Phone

Relationship to Patient

Birthdate

Social Security Number

Driver's License Number

Responsible Person Employed By

Address

Position

Work Phone

Spouse

Employer

Address

Work Phone

Position

Birthdate

Social Security Number

Primary Dental Insurance

Address

Group #

ID #

Employee Name

Company Name

Address

Secondary Dental Insurance

Address

Group #

ID #

Employee Name

Company Name

Address