Informed Consent

SHINDE`S DENTAL CLINIC Dr. Sandip Shinde B.D.S.(Dental surgeon)

Reg. No. Mo. 7721859191

PATIENT RECORD CARD Name: Age: Address:

Sex:

Date: Mo: Case Paper No:

. . .

History Medical: Dental: allergies to any drug:

. . .

INFORMED CONSENT I Mr./Mrs. / Ms. Give informed consent to Dr. Sandip Shinde for any such treatment to me/my ward as may be required in the interest of me / my wards Oral & Dental health and under any anesthesia deemed suitable if required for the procedure. I understand that necessary information will be given to me from time to time on every proposed treatment procedure and I have been explained about limitation & consequences of the procedures. I agree to pay the fees for above treatment procedures and will abide by it. I give consent for any change in anesthesia / treatment plan as deemed necessary by the doctor at the time of medication / investigation / procedure / therapy. Signature of Patient/ Patient's Guardian Date: Time:

ससससस सससस सस ससससस सससस ससससस सससस / सससस सस , सससससससस / सससससस ससससससससससस ससससससस सससससससस / सससससस / ससससस सससससस ससस सस . ससससस ससससस ससससस ससससससस सससससससस ससस ,ससस ससससससससससससस ससससससससस ससससस सस ससस सससससससस ससससससस ससस सससस सससससससस सससससससस ससससससस सससससससस सससससस सससस सससस ,सस सससससससससस सससससससस ससससससस ससससस सससस. सससससससससस सससससससससससस ससससस ससससससस / सससस ससस ससससस सससस . सससस ससससससससस ससससससससससससस ससससससस सससससससससससस ससससस ससससससससससस सस ससस ससससस ससससस सस सससससस ससससस सससससस

ससस सससससससससस सससस सससस सस ससस ससससस ससस . ससससस / ससससससससस ससससससससससस ससस सससससस : ससस :

Chief Complaint:

.

 Tretment Plan: RCT: Filling:

. .

Extraction: Any Other:

Date

.

. .

Treatment Done

Payment Done

Balance