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.

Appointment Cost

The estimated cost for this appointment (exam, x-rays, and cleaning) 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.

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: