C110.1.01 Rev6.22.17 green General Treatment Consent - Adult Pa�ent Name ___________________________________________________ I give my consent to receive dental treatment, educa�on, and other dental-related services. I authorize the administra�on of anesthe�cs, as may be considered necessary, and the use of oral x-rays during the treatment. I will receive instruc�ons about the benefits and risks of the necessary procedures, and I will have the opportunity to discuss and approve the recommended treatment. I acknowledge that I have not received guarantees, warran�es, or representa�ons concerning the results of the treatment or procedures. I accept the responsibility to follow oral hygiene and post-op instruc�ons, come to all the appointments on the proper day and �me, provide accurate and updated health informa�on, and alert this office of anything that may adversely affect the treatment. By consenting to treatment, I understand there is risk of infectious diseases. Despite taking reasonable precautions to ensure your health and safety, it is impossible to eliminate all risk of contracting an infectious disease while receiving dental care. I have the right to withdraw this consent at any �me. I will s�ll be responsible for the unpaid balance and for any complica�on arising from the treatment interrup�on. Signature________________________________________________________Date ______________________ I refuse or withdraw my consent for treatment Signature________________________________________________________Date ______________________ Witness Signature_________________________________________________ Date ______________________ Summary of No�ce of Privacy Prac�ces Our Privacy Practices comply with Omnibus 2013 Mortenson Family Dental keeps informa�on of all your dental visits. We are required by law to maintain the privacy of your protected health informa�on and to provide you with no�ce of our legal du�es and privacy prac�ces with your informa�on upon request. You can also find the No�ce on our website. This no�ce is a detailed explana�on on how we may use your protected health informa�on and your rights to inspect and amend your informa�on. Law requires us, and by our code of ethics, to keep your informa�on private, and to follow the prac�ces outlined in this No�ce. Our Privacy Prac�ces comply with Omnibus 2013 and are updated effec�ve 09/23/2013. I have had full opportunity to read and consider the contents of this office’s No�ce of Privacy Prac�ces. I understand I am giving my permission to use and disclose my protected health informa�on to use in treatment, payment ac�vi�es, and healthcare opera�ons. I also understand that I have the right to revoke or modify this permission. Print Name: ____________________________ Signature _________________________________ Date _____________ An emergency situa�on prevented us from obtaining acknowledgment Other (Please Specify) Individual refused to sign Communica�ons barriers prohibited obtaining the acknowledgment For Office Use Only We a�empted to obtain wri�en acknowledgment of receipt of our No�ce of Privacy Prac�ces, but could not obtain acknowledgment because:

General Treatment Consent - Adult · C110.1.01 Rev6.22.17 green General Treatment Consent - Adult Pa ent Name _____ I give my consent to receive dental treatment, educa on, and other

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C110.1.01 Rev6.22.17 green

General Treatment Consent - Adult

Pa�ent Name ___________________________________________________

I give my consent to receive dental treatment, educa�on, and other dental-related services. I authorize the administra�on of anesthe�cs, as may be considered necessary, and the use of oral x-rays during the treatment. I will receive instruc�ons about the benefits and risks of the necessary procedures, and I will have the opportunity to discuss and approve the recommended treatment. I acknowledge that I have not received guarantees, warran�es, or representa�ons concerning the results of the treatment or procedures.

I accept the responsibility to follow oral hygiene and post-op instruc�ons, come to all the appointments on the proper day and �me, provide accurate and updated health informa�on, and alert this office of anything that may adversely affect the treatment.

By consenting to treatment, I understand there is risk of infectious diseases. Despite taking reasonable precautions to ensure your health and safety, it is impossible to eliminate all risk of contracting an infectious disease while receiving dental care.

I have the right to withdraw this consent at any �me. I will s�ll be responsible for the unpaid balance and for any complica�on arising from the treatment interrup�on.

Signature________________________________________________________Date ______________________

I refuse or withdraw my consent for treatment

Signature________________________________________________________Date ______________________

Witness Signature_________________________________________________ Date ______________________

Summary of No�ce of Privacy Prac�cesOur Privacy Practices comply with Omnibus 2013

Mortenson Family Dental keeps informa�on of all your dental visits. We are required by law to maintain the privacy of your protected health informa�on and to provide you with no�ce of our legal du�es and privacy prac�ces with your informa�on upon request. You can also find the No�ce on our website. This no�ce is a detailed explana�on on how we may use your protected health informa�on and your rights to inspect and amend your informa�on. Law requires us, and by our code of ethics, to keep your informa�on private, and to follow the prac�ces outlined in this No�ce. Our Privacy Prac�ces comply with Omnibus 2013 and are updated effec�ve 09/23/2013.

I have had full opportunity to read and consider the contents of this office’s No�ce of Privacy Prac�ces. I understand I am giving my permission to use and disclose my protected health informa�on to use in treatment, payment ac�vi�es, and healthcare opera�ons. I also understand that I have the right to revoke or modify this permission.

Print Name: ____________________________ Signature _________________________________ Date _____________

An emergency situa�on prevented us from obtaining acknowledgment Other (Please Specify)

Individual refused to sign Communica�ons barriers prohibited obtaining

the acknowledgment

For Office Use OnlyWe a�empted to obtain wri�en acknowledgment of receipt of our No�ce of Privacy Prac�ces, but could not obtain acknowledgment because: