I consent to be a patient at Ormson Family and Cosmetic Dentistry, and agree to a radiographic and clinical
examination. I also understand and consent to the following:
During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum
treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns,
bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep
apnea treatment, oral pathology, pediatric dentistry, and radiography.
I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and
consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health
No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any
branch of medicine,\ including\ dentistry, can involve unanticipated results.
I will pay in full any cost of treatment or insurance copayments according to the office's financial policy. I
understand that even if an insurance pre estimate is given or a procedure has been preapproved, I am responsible
for any costs that my insurance does not cover.
My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open
communication with my dentist, hygienist, and dental office staff.
I am welcome to ask questions about any aspects of my dental care and will request information if I am confused
or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.