Informed Consent Aleksandra Morel, DDS Family and Cosmetic Dentistry 5501 independence Pkwy., Suite 205 Plano, TX 75023 Informed Consent Patient Name i understand that am in a dental office seeking dental evaluation and/or dental care. I understand that Dr. Morel is a general dentist who received her education at Baylor College of Dentistry; Dallas, Texas. I understand that I must disclose all of the medical information to the doctor and notify of any changes that may occur during the course of treatment. It is important to list all of the drugs that I take and state any known allergies. I understand that most of the procedures are performed under local anesthesia. This type of anesthetic is by far the most common form used in dentistry. You will receive an injection of a local anesthetic during most of the procedures. An additional fee is NOT charged for this anesthesia service. I am allergic to. I consent to having composite fillings placed in my mouth when advised by a dentist. Composite fillings are tooth colored. We do not place amalgam (silver) fillings in this office. l understand that payment is required on the day of service. I understand that Dr. Morel and her staff will file dental insurance claims for me, but are not responsible for the remaining unpaid portion. Dental insurance does not always pay for the services provided by your demist. The best way to learn how much your carrier may pay is to file a predetermination claim. l read every paragraph carefully and understood it well. Signature and date Witness Translated by CAPTCHA Δ
