Consent Form

This form must be completed no later than 48 hours before your scheduled appointment.

Patient Information

Consent Statement

I, [Patient Name], consent to the dental appointment scheduled with Watagan Dental on the date and time listed above. I understand that this appointment may involve a comprehensive exam, dental x-rays, and a professional dental cleaning, as well as the development of a personalized dental care plan with recommended treatments and costs. I acknowledge that:

• I have been informed about the purpose and nature of the appointment.

• I have had the opportunity to ask questions about the procedures and costs.

• I agree to arrive 10 minutes early for my appointment.

• I understand that failure to confirm my appointment 48 hours prior may result in cancellation.

• I understand failure to attend my appointment on the day will incur a $75 late cancellation fee. This fee is also charged if the patient decides they do not want to attend on the day regardless of congnitive state as it covers our staffing cost for the appointment.

Appointment Cost

The estimated cost for this appointment is:

I acknowledge the estimated cost and agree to pay this amount either through the online portal or in person on the day of the appointment. Partnered facilities have a slighly reduced travel fee as we will be seeing multiple patients at one location.

Unexpected Costs Consent

I understand that unexpected costs may arise during my appointment due to additional procedures or treatments deemed necessary by the dental professional. I consent to additional costs as follows:

• I authorise Watagan Dental to perform additional procedures if necessary.

If costs exceed this amount, I request to be consulted before proceeding with additional procedures.

Health Fund Claiming Consent

• The full amount of the visit must be paid before the appointment, or

• Payment will be taken from my nominated credit card immediately after treatment.

• Nominated Credit Card Details (if applicable):

Patient Signature

I confirm that the information provided is accurate, and I consent to the appointment, costs, and health fund claiming process as outlined.

Next of Kin or Legal Guardian (if applicable)

If the patient is a minor or requires a guardian, the next of kin or legal guardian must also provide consent: