PRIVATE ERDEM AZIM ORAL AND DENTAL HEALTH POLYCLINIC
PATIENT CONSENT FORM
Date
Patient’s Surname,
Name
Protocol No
Dear Patient/Patient’s Relative
It is your utmost natural right to know about your illness and recommended procedures and therapies for the diagnosis and
therapy of your illness. After getting informed about the benefits and possible risks of the medical treatment; whether or not
to consent with the process to be performed is subject to your own decision. If you wish, all the data and documents
concerning your oral health can be given either to you or to one of your relatives to be nominated by you. You may refuse to
be informed except for cases that require legal and medical obligations. You may revoke your consent at any time you wish.
This situation will not affect your future therapies under any circumstances whatsoever. However, your right to do so is
contingent on the condition that “there is no medical inconveniency “. When this situation exists, a statement for the Revoke
of Informed Consent shall be issued and attached to this form.
I the undersigned or the legal guardian has been informed by the dentist …………………about the condition of my
oral health.
Concerning the diagnosis/therapy of my illness ………………. I am informed about the implementation
of ………………………….
Probable unwanted side effects and possible risks are explained in detail.
Issues needed to be cared for before and after the treatment are explained.
When refuse this diagnostic/therapeutic process; I am informed about the risks that might affect my health and
whether or not there are any other diagnostic/therapeutic procedures that might be implemented in lieu of this
diagnostic/therapeutic process.
Necessary details regarding the possible costs of this diagnostic/therapeutic process are explained to me.
I am told that the dentist, if necessary, may acquire consultation from other medical doctors during the
diagnostic/therapeutic process and that another medical doctor may participate in this diagnostic/therapeutic
process.
I hereby consent the application of …………………. treatment on myself/on the patient I am representing by and
under the authority, supervision and methodology of the dentist ….…………………….’s at PRIVATE ERDEM AZIM ORAL AND DENTAL HEALTH POLYCLINIC.
( ) Verbal information is provided.
( ) Read the informative booklet, understood and accepted the content.
( ) I hereby allow that my photographs at the clinic can be taken for training, diagnosis, follow-up and for scientific .
purposes by keeping my identity details secret and can be used for scientific, training and research purposes
together with clinical findings
This is to certify that I have fully understood and answered the questions asked to me by Dentist ………………. as
well as the issues noted in the information form and accept the treatment to be applied to me by my dentist under the
light of the information explained.
NOTE: …………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..
Name,
Last Name
Signature
Patient/Legal Representative*
Witness
Translator
Healthcare Personnel in Charge
Thanks for sharing. I read many of your blog posts, cool, your blog is very good.
Very nice post. I just stumbled upon your blog and wanted to say that I’ve really enjoyed browsing your blog posts. In any case I’ll be subscribing to your feed and I hope you write again soon!
Great content! Super high-quality! Keep it up!
you have a great blog here! would you like to make some invite posts on my weblog?
We thank you. People often come to our clinic on recommendation. We do not intend to invite people to our clinic on sites other than our site in any way.
I got to admit, this post is pretty good. Actually, it’s one of the best I’ve come across in a long time.
I’m glad I found this page. I was searching for another website when I stumbled on it. Nice work.
At last, something worth reading. It’s always nice to find postings like this one.
Thanks for posting. I really enjoyed reading it, especially because it addressed my problem. It helped me a lot and I hope it will help others too.
I just left a webpage similar to this one, but the material wasn’t as engaging as what’s here.
This is a really nice post. It’s very informative and well written. I’ll check back for more posts like this one.
You helped me a lot with this post. I love the subject and I hope you continue to write excellent articles like this.
Wow, that’s what I was exploring for, what a data! existing here at
this website, thanks admin of this web site.
Please provide me with more details on the topic
You helped me a lot by posting this article and I love what I’m learning.
Thank you for your articles. They are very helpful to me. Can you help me with something?
It抯 really a cool and useful piece of info. I am happy that you simply shared this helpful info with us. Please keep us informed like this. Thanks for sharing.
There are definitely a whole lot of details like that to take into consideration. That could be a nice level to deliver up. I provide the thoughts above as basic inspiration however clearly there are questions like the one you carry up where the most important thing will be working in sincere good faith. I don?t know if finest practices have emerged round issues like that, but I am certain that your job is clearly identified as a fair game. Both boys and girls really feel the impact of only a second抯 pleasure, for the rest of their lives.
Hey! This is my 1st comment here so I just wanted to give a quick shout out and say I really enjoy reading your posts. Can you suggest any other blogs/websites/forums that cover the same topics? Thanks for your time!
This is a perfect example of good content. You can tell that plenty of thought when into this post. Nice work.
The next time I learn a weblog, I hope that it doesnt disappoint me as much as this one. I mean, I do know it was my choice to learn, however I really thought youd have one thing interesting to say. All I hear is a bunch of whining about something that you possibly can fix if you werent too busy looking for attention.
Now this is quality content. You can tell that alot when into this post. Keep it up.
Interesting content. I’m glad I found this page. I’m going to save it so I can read any future posts.
Hey very nice website!! Man .. Excellent .. Amazing .. I’ll bookmark your website and take the feeds also厈I am happy to find numerous useful information here in the post, we need work out more strategies in this regard, thanks for sharing. . . . . .
Hey! This post could not be written any better! Reading through this post reminds me of my good old room mate! He always kept talking about this. I will forward this article to him. Pretty sure he will have a good read. Thanks for sharing!
Very efficiently written article. It will be useful to anybody who usess it, including me. Keep doing what you are doing – for sure i will check out more posts.
Somebody essentially help to make seriously articles I would state. This is the first time I frequented your website page and thus far? I surprised with the research you made to create this particular publish incredible. Excellent job!
Hello, you used to write wonderful, but the last several posts have been kinda boring?I miss your super writings. Past several posts are just a little bit out of track! come on!
My brother recommended I might like this blog. He used to be entirely right. This submit actually made my day. You can not believe just how a lot time I had spent for this info! Thank you!
Wonderful beat ! I would like to apprentice at the same time as you amend your website, how could i subscribe for a blog web site? The account helped me a appropriate deal. I had been tiny bit familiar of this your broadcast provided shiny clear concept
This is a really nice page. It’s very engaging and well written. I’ll come back from time to time for more posts like this one.
Nicely written post. I honestly like the subject matter discussed here. I’ll come back from time to time for more posts like this one.
Great post. It’s very well thought out and quite educating. Keep it up.