Please read and initial the work to be done below, then read and sign the section at the bottom of the form DRUGS AND MEDICATION I understand that antibiotics, analgesics and other medications may cause allergic reaction causing redness, swelling of tissues, pain, itching and vomiting, and/or anaphylactic shock. I understand that the administration of local anesthetics may result in temporary or permanent paresthesia (numbness) of involved teeth, tissues, and associated structures. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain, and potential resistance to effect treatment of my condition. I accept these risks by consenting to the use of local anesthetics during my dental appointments. If I have a medical condition that necessitates antibiotic pre-medication before dental treatment, it is my responsibility to notify the dentist. I assume all responsibility for all medical consequences if the dental office is unaware of my need for pre-medication. * Clear Signature I understand that dentistry is not an exact science; therefore, reputable practitioners cannot properly guarantee results. I acknowledge than no guarantee or assurance has been made by anyone regarding the dental treatment that I have authorized. I hereby authorize the doctors and staff members to proceed with and perform dental treatment as explained to me * We will not be liable for any loss or damages arising from this product, whether direct, indirect, special, incidental or consequential, regardless of the theory asserted including warranty, contract, negligence or strict liability. In the event that a course of treatment recommended by a dentist is not followed, or an alternative treatment course is chosen instead of recommended treatment plan, the treatment will not be covered by a dental warranty. The applicability of the dental warranty in relation to the course of treatment followed will be indicated by dentist. Our aim at MILPITAS SQUARE DENTAL is to provide you with the very best possible standard of dental care, tailored to meet your specific needs, and to do this in the most timely manner and with the utmost of comfort for you. We want you to have a very positive experience with us, and gain the best treatment outcome. You adherence to these preceding terms and conditions of treatment will allow us to provide the best care for you that we can. * Clear Signature PROCEDURE TO BE PERFORMED * PATIENT’S PRINTED NAME * PARENT/LEGAL GUARDIAN (if minor) *
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