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Informed Consent for Dental Prophylaxis (cleaning). Exams. & X-rays

    Dear Dr. Pollak DMD PC,

    During dental Prophylaxis (Cleaning), I/Caregiver understand that it involves removing plaque and calculus above the gum line and will not include gum infections below the gum line called periodontal disease. I understand bleeding could last several hours. Should it persist, or is severe then you should receive attention immediately and this office must be contacted.

    Exam and X-rays
    I understand that the initial visit as well as recall appointments may require radiographs in order to complete the examination, diagnosis and treatment plan.

    Patient/Caregiver Address:

    City:

    State:

    Zip Code:

    Phone Number:

    Email:

    By signing below, I/Caregiver acknowledge that I have read, understood, and discussed the information provided above, and I willingly consent to treatment.

    Your Signature/Caregiver

    Date:

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