Name Address Place Pincode Telephone O.P No. Date Age Sex MaleFemaleTransgender D.O.B Blood Group Email Id Medical History Drug Allergy YesNo I hereby authorize and direct that dentist(s) assisted by other dentists of his choice, to perform upon myself or my child (or legal ward for whom I am empowered to consent) the checked dental treatment(s). I certify that I have read and understand this consent form, that I have been given an opportunity to ask questions, and that all questions about the procedure(s) having answered in a satisfactory manner. No guarantee has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. I understand further that I have the right to be provided with answers to question that may arise during the course of my treatment or that of my child. I further understand that I am free to withdraw my consent to treatment at any time, and that this consent will remain in effect until such time that I choose to terminate it. I have been advised that medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and co ordination, thus I have been advised not to operate any vehicle or hazardous device for atleast 24 hours or until fully recovererd from the effect of the anesthetics, medications and drugs that may have been given me for my care. I agree not to drive myself home and to have a responsible adult accompany me until I Am recovered from my medications. Signature of Patient/Guardian Reimbusement YesNo Payment CashCard Chief Complaint Dental Examination Diagnosis Treatment Plan
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