Dental (E) Dental Consent 09.2020 - Approved

Dental Consent Form
Name of Patient
Date of Birth of Patient

Month Day Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
I, the undersigned, hereby give my consent to the Urban Inter-Tribal Center of Texas and its Dental staff to examine, take any necessary x-rays, administer tests, prescribe therapy and perform procedures that are deemed necessary.

I realize that upon my signing the consent for treatment, I may present myself or my child for diagnoses and treatment for illness, defects, or complaints. I do hereby give my qualified consent for treatment, as necessary, at any time I/my child come(s) to the clinic.

If patient is a minor:

I certify that I am the parent/legal guardian of the aforementioned minor and have full authority to give this consent for dental treatment of such minor and that my authority to do so has not in any way been limited or removed by any court of law.

I certify that I have read and understand and accept the treatment plan presented to me.
Signature of Patient/Parant or Legal Guardian

Clear
Date

Month Day Year
Date
Person to be Contacted in Case of Emergency:
Name:
Address:
Phone Number:
Should be Empty: