Crown & Veneers Consent Form
Treatment- Prosthodontic treatment for Full Mouth Rehabilitation
I
hereby give my consent to proceed with prosthodontic
treatment (Crowns & Veneers) IRT following tooth numbers:
54321 1234567
54321 12345
The final decision is to take ________as final shade.
By signing this document, I am freely giving my consent to allow and authorize my
Dentist to render treatment necessary and/or advisable to my dental conditions
including the prescribing and administering of any medications and/or anesthetics
deemed necessary to my treatment. The fee(s) for service is
_________________________ and is agreed upon.
Signed _________________________________ Date/ Time _______________
Patient / Parent / Guardian
Witness signature______________
Date/ Time _______________