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COMPLETE LIST OF FORMS
GENERAL INFORMED CONSENT
SPECIALTY CONSENT
PROPHYLAXIS & PHOTOGRAPHY
TREATMENT REFUSAL
PATIENT DISMISSAL, CLAIMS RELEASE
EMPLOYEES
ANNUAL FORMS PACKAGES
INFORMED CONSENT LAW
CONTACT
SECURE ORDERING
REQUEST A FORM
DISCLAIMER, LICENSE, & LIABILITY LIMITS
PATIENT EDUCATION, REGISTRATION
CONSCIOUS SEDATION FORMS
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DENTAL OFFICE & EMPLOYEE MANUALS
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GENERAL INFORMED CONSENT
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General Informed Consent:
Consent for General Dentistry
$10.00
General Informed Consent for Dentistry:
Includes blanks to fill in specific procedures to be performed. Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Extractions
$10.00
ldf.com ext1
Comprehensive informed consent for all tooth extractions.
Includes:
blanks to record blood pressure and pulse on date of extraction(s), as well as blanks for dentist signature and foreign language interpreter signature (if needed). Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for extractions, addresses patient expectations, and treatment alternatives.
Consent for Multiple Areas of Dentistry (
English
)
$10.00
Informed Consent for Multiple Areas of Dentistry (in English): Areas of treatment include Oral Surgery, Periodontics, Endodontics, and Crown & Bridge.
Also includes:
blanks to fill in blood pressure and pulse, as well as specific teeth on which procedures to be performed. Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Multiple Areas of Dentistry
(Spanish)
$10.00
Informed Consent for Multiple Areas of Dentistry (in Spanish): Areas of treatment include Oral Surgery, Periodontics, Endodontics, and Crown & Bridge.
Also includes:
blanks to fill in blood pressure and pulse, as well as specific teeth on which procedures to be performed. Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Crown & Bridge
$10.00
Consent for Crown & Bridge
: Includes blanks to fill in tooth numbers to be prepared and restored. Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for crowns and/or bridges, addresses patient expectations, and treatment alternatives.
Consent for Dentures
$10.00
Consent for Dentures:
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for complete dentures, addresses patient expectations, and treatment alternatives.
Consent for Nitrous Oxide Anesthesia
$10.00
Consent for Nitrous Oxide Anesthesia:
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Local Anesthetic
$10.00
Informed Consent for Use of Local Anesthetic: Includes blanks to record blood pressure and pulse.
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for I.V. Sedation
$10.00
ldf.com ivsed
Consent for I.V. Sedation: Includes blanks to record blood pressure and pulse on date of sedation procedure.
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Teeth Whitening
$10.00
ldf.com white
Informed Consent for Teeth Whitening: Comprehensive 4-page form.
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Botox(tm) Injection(s)
$10.00
Informed Consent for Botox(tm) Injection(s):
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
Consent for Dental Treatment While Using Oral Bisphosphonates
$10.00
ldf.com bisph
Informed Consent for Dental Treatment While Using Oral Bisphosphonates.
Discloses the risks or hazards that could influence a reasonable person in making a decision to give or withhold consent for treatment, addresses patient expectations, and treatment alternatives.
PEDIATRIC PATIENT MANAGEMENT
$10.00
Form thoroughly explains for parental/guardian consent that there are several behavior management techniques that are used by pediatric dentists to gain the cooperation of child patients to eliminate disruptive behavior or prevent patients from causing injury to themselves due to uncontrollable movements.
Gingival Augmentation/Gum Graft Surgery
$10.00
Gingival Augmentation/Gum Graft Surgery:
The purpose of gingival augmentation is to create an amount of attached gum tissue adequate to reduce the likelihood of further gum recession, or to cover exposed root surfaces, enhance the appearance of the teeth and gum line, or prevent/treat root sensitivity or root decay.
Complies with TSBDE Rule 108.7 which requires that Texas dentists maintain a written informed consent signed by the patient, or a parent or legal guardian of the patient if the patient is a minor, or a legal guardian of the patient if the patient has been adjudicated incompetent to manage the patient's personal affairs. Such consent is required for all treatment plans and procedures where a reasonable possibility of complications from the treatment planned or a procedure exists, and such consent should disclose risks or hazards that could influence a reasonable person in making a decision to give or withhold consent.
Cone Beam CT Scan
$10.00
Informed Consent for Cone Beam CT Scan.
