CARLSTON DENTAL GROUP

CARLSTON DENTAL GROUP
YOUR INFORMATION
Name

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Email
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Address

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Referred By
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INSURANCE INFORMATION

Primary Dental Insurance
Carrier
Address

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Phone
FAX
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Insured ID#
Group, Policy #
Insured's Name
Relation
DOB

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Date
Employer
How Long
Employer
Secondary Dental Insurance
Carrier
Address

Street Address

Street Address Line 2

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Phone #
Insured ID#
Group, Policy #
Insured's Name
Relation
DOB

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Date
Insured's Employer
RESPONSIBLE PARTY INFORMATION
Name
Relation
Address

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Date

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Work Phone
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Cell Phone
CC Exp. DT
CC Sec. CDE
Credit Card
INIT
I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance carrier.

CARLSTON DENTAL GROUP
Informed Consent for X-Rays, Cleaning, Local Anesthetic and Communications

X-rays:

Proposed treatment: taking of intraoral and extraoral radiographs.

Benefits of treatment: taking x-rays enables us to view dental cavities, abnormalities, development and eruption of teeth. They are also necessary for proper diagnosis and evaluation purposes.

Alternatives of treatment: none; limited visual examinations

Common Risks: radiation exposure to soft and hard tissues.

Consequences of not performing the treatment: missed diagnosis.

I have been advised by the dentist that x-rays are necessary to be certain that any oral disease or condition is diagnosed. I acknowledge at this time and that I REFUSE these x-rays and that I am aware of the consequences of this refusal.
Don't sign this unless you want X-rays

Clear
Date

MonthDayYear
Date
Cleaning:

Proposed treatment: involves thorough cleaning of teeth to help heal inflamed or infected gum tissue. It involves removal of plaque build-up and harder calculus deposits above and below the gum line.

Benefits of treatment: healthy oral environment; also, reduction/elimination of bleeding, odor and periodontal disease.

Alternatives of treatment: referrals for periodontal (gum) surgery according to the severity of condition.

Common risks: bleeding, soreness, swelling, infection of tissue, hot and cold sensitivity, stiff or sore jaw joint.

Consequences of not performing the treatment: discontinued or interrupted treatment could result into further inflammation and infection of gum tissue, lead to more tooth decay, and deterioration of surrounding bone structure which could lead to tooth loss.

Local Anesthetic and Nitrous Oxide:

Proposed treatment: injection of local anesthetic to surrounding oral tissues. Nitrous Oxide will not be used unless agreed to in advance of any specific procedure.

Benefits of treatment: numbness of tissue and muscle surrounding area of treatment to eliminate pain sensation.

Alternatives to treatment: dental restorations performed with no anesthetic resulting in severe sensitivity and pain.

Common risks: allergic reaction, irritation to nerve tissue, stiff or sore jaw joint, swelling of tissue, bruising and may cause temporary or permanent paralysis.

Consequences of not performing the treatment: severe pain and sensitivity.
Communications
Initial
- I allow Dr. Carlston's staff to communicate with me with regard to delivery of dental services, responses to inquiries, treatment follow-up, or appointments by text, email, phone calls or by mail unless specific other instructions are given.
- I have read and understand the entire information on this consent form, which includes x-rays, cleaning, local anesthetic, nitrous oxide and communications. All my questions were answered to my full understanding and satisfaction.
Signature of patient, parent, or legal guardian:

Clear
Date

MonthDayYear
Date
Should be Empty: