Skip to main content

Dr. Chen Dentistry

  • 2813 Coltsgate Road Suite 100, Charlotte NC 28211
Make Appointment

Consent for Treatment

PEDIATRIC DENTISTRY CONSENT for DENTAL PROCEDURE and ACKNOWLEDGEMENT of RECEIPT of INFORMATION
Please read this form carefully. If you do not understand something to your satisfaction please ask questions. We will explain it.
I hereby authorize and direct Dr. Stephanie Chen, assisted by dental auxiliaries of her choice, to perform the following dental treatment which, in general terms, the dental procedure(s) or operation may include:(Required)

This treatment willbe explained to me by Dr. Chen, the hygienist or dental assistant. Alternative methods of treatment, if any, will also be explained to me. I am advised that, though good results are expected, the possibility and nature of complications cannot be completely anticipated. Therefore, there can be no guarantee as expressed or implied either as to the result of the treatment or as to the cure. I further authorize Dr. Chen to perform other dental services that, in her judgment, are advisable for my child or legal ward.

I hereby state that I have read and understand this consent, and that all questions about the procedure or procedures have been answered in a satisfactory manner and I understand that I have the right to be provided with answers to questions which may arise during the course of my child's treatment.

I further understand that this consent will remain in effect until such time that I choose to terminate it.

Clear Signature
Clear Signature
Clear Signature
(Required)