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INFORMED CONSENT FOR SNAP ON SMILE

I hereby request and authorize Dr. Darren Ramsey DDS and whomever he may designate as his assistant(s), to perform upon me the following procedure(s): Snap On Smile 

1. I, on behalf of myself and my heirs, executors and administrators hereby release any and all claims, rights, liabilities and causes of action, known or unknown, that I may have against the above dentist and his/her staff as well as Build A Smile and its officers, directors, employees, successors and assigns arising from or related to the manufacture, supply, development and installation of a custom made dental appliance known as the Snap-On Smile for my teeth and any other procedure(s) that Dentist performs in connection therewith.

2. I authorize the performance of additional procedures and changes of planned procedures if, in the judgment of Dentist, this will be necessary to improve my safety and the results contemplated by the procedure. 

3. I have been provided with information by Dentist of the specific treatment planned for my case in order that I may be able to make an informed decision about the treatment. I fully understand that Dentist will use his/her best judgment and skill to accomplish the desired results. The following has been explained to me to my satisfaction, in language that I understand: my diagnosis, the anticipated procedure(s), the attendant risks and complications, alternatives, including doing nothing at all, the post-operative course, and possible variables. I understand that I am able to take as much time as I need to come to a decision whether to sign this form and to undergo the proposed treatment, and I acknowledge that I have had the opportunity to ask questions about the treatment before consenting to accept and undergo the treatment. I understand that I may stop plans for this treatment at this time or ask further questions if I desire. I also understand that there may be other doctors who are specialists in these procedures and that I have the opportunity to be treated by them and to choose alternative options to the treatment. However, I prefer to have the treatment and procedures identified above performed in this office by Dentist.

4. I understand that, although unusual, unexpected complications or less than desired results can occur, and this may result in the need for additional dental procedures, and the possibility of further expense to me.

5. I understand that excellent home care techniques, using a variety of aids, may add considerably to the successful outcome of my dental restorative program, and I understand it will be important for me to follow the home care instructions, both written and oral, very carefully. I also understand that the Snap-On Smile dental appliance is to be removed before sleeping for my personal safety as well as to extend the life of the product. 

6. I understand that effort will be made to make my teeth appear as straight as possible with  Snap-On Smile, but because of the existing position of my natural teeth, which are not in perfect alignment, there is no guarantee that this can be accomplished. In addition, I understand that the Snap-On Smile appliance will add minimal bulk to my teeth and that I will need to get used to the addition of the Snap-On Smile to my teeth. By signing this informed consent form, I am confirming that I have read the above prior to signature and understand this document and the proposed treatment in full, including its possible risks, complications, and benefits, that all of my questions have been answered to my satisfaction, and that I consent to, and authorize Dentist to proceed with, the necessary treatment as proposed, following the establishment of financial arrangements. I understand that I am ultimately responsible for my account and any balances. 

I Understand that all deposits, partial, and full payments are NON-REFUNDABLE

 

 

First Patient's Name

First Name*

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First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

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Second Patient's Date of Birth*
Third Patient's Name

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Third Patient's Date of Birth*
Fourth Patient's Name

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Fourth Patient's Date of Birth*
Fifth Patient's Name

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Fifth Patient's Date of Birth*
Sixth Patient's Name

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Sixth Patient's Date of Birth*
Seventh Patient's Name

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Seventh Patient's Date of Birth*
Eighth Patient's Name

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Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

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Ninth Patient's Date of Birth*
Tenth Patient's Name

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Tenth Patient's Date of Birth*
Parent or Guardian's Email Address

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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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