Dental Treatment Consent & Health History Form

AUTHORIZATION FOR DENTAL TREATMENT
I authorize the Dental Staff of RCH to administer dental treatment to First Name* Last Name* as they deem necessary. I also authorize the use of any anesthetics and/or medications, with the exception of those that I have listed on the Medical/Dental Health history form (allergy or other reason for not taking a medication). I acknowledge that no guarantee of assurance has been made relative to the results which may be obtained.
I hereby certify that I have read and fully understand the authorization for dental treatment.
Signature*

Clear
Date*

MonthDayYear
Date
Parent/Legal Guardian Signature (If patient is a minor)

Clear
Relationship to Patient

AUTHORIZATION FOR DENTAL TREATMENT