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EXTRACTION & OTHER PROCEDURES CONSENT / WAIVER
The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it sometimes is impossible to give an accurate estimate before sedation. From an economic standpoint, it is much more economical to complete all needed dental procedures during the initial visit and sedation rather than having to schedule another appointment with additional sedation required. In an effort to satisfy your desires, please mark the appropriate option below:
[ ] Please perform whatever procedures & extractions are required at this time.
[ ] Please perform whatever procedures & extractions are required up to $__________.____
[ ] Please do nothing more than the requested dental prophy procedure at this time.
[ ] Please call me after the exam with an estimate if any additional procedures are needed. Do not proceed without authorization. If you choose this option please make sure that you can easily be reached between 9am - 1pm for authorization otherwise no additional procedures will be performed and additional anesthetic procedures may be required.
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