Consent & Notice of Privacy Practices
I authorize the diagnosis of my dental health by means of radiographs, study models,
photographs, and/or other dental diagnostic means. I acknowledge that, because the practice of dentistry
is not an exact science, no guarantees have been made to me. I agree that it is my responsibility to
follow through with recommended treatment and/or follow-up evaluations. Failure to do so may result in
pain, discomfort, loss of teeth, and/or other complications.
Allergic reactions can occur due to any medication, anesthetic or dental material used. In rare
cases, injectable anesthetics may cause temporary or permanent nerve damage. The effects of x-rays
may be harmful to an unborn fetus. Please inform us if there is any possibility that you may be pregnant.
Patients with artificial joints or implanted devices are at risk of developing endocarditis. Endocarditis is an
infection of the heart valves that can result from any dental procedure involving bleeding. In order to
prevent endocarditis, it may be necessary to administer antibiotics prior to treatment. Patients with TMJ
problems (jaw/ear clicking) must inform us of their condition prior to treatment to avoid further injury.
I have the right to refuse or accept any treatment proposed to me. Not objecting to treatment
indicates that: I give permission for the treatment to be rendered; I understand the reasons for the
treatment; I am aware of the risks involved in the treatment; I am aware of alternative treatments; I
understand that no guarantees have been given to me; and, I will comply with home care instructions
and recommended additional treatment.
I authorize the dental practice to release any information, including the diagnosis and records of
treatment or examination for myself and my dependents, to third-party insurance carriers, payers, and/or
healthcare practitioners. If I fill a prescription for a controlled substance, I understand that my identifying
information may be entered into a statewide database of controlled substance prescriptions. The
database is called the Prescription Drug Monitoring Program.
I authorize the payment from my insurance carrier to be submitted directly to the dentist or
dental practice. I assume financial responsibility for any outstanding balance for services that are not
fully covered by insurance. I understand that insurance estimates given to me are not guaranteed, and
that final payment determination will be made by the insurance company upon processing of the claim. I
agree to pay any deductible amount, co-insurance or any other balance not paid for by the insurance
company. I understand that a late fee and/or a Finance Charge of 1.5% per month (18% APR) may be
applied to past due accounts. I understand that all collection costs, attorneys’ fees, and court costs are
my responsibility.
I understand that State and Federal laws, as well as ethical and licensure requirements impose
obligations with respect to patient confidentiality that limit the ability to make use of certain services or to
transmit certain information to third parties. I understand that Butterman Dental PC will comply with all
applicable laws governing the gathering, use, transmission, processing, receipt, reporting, disclosure,
maintenance, and storage of my information. I understand that Butterman Dental PC will use
commercially reasonable efforts to maintain the confidentiality of all patient information. You may request
a copy of our Privacy Notice from us at any time.
I hereby certify that I have read and understand the above information and that it is accurate
and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate
information has the potential of being hazardous to my health. It is my responsibility to provide accurate
information regarding my medical history and to timely advise of any changes with respect to my medical
history. If I did not understand any part of this document, I have asked for and received clarification. By
signing this document, I am indicating that I have read and understood the above information.