Desert Sky Consent Form

  • DESERT SKY DENTAL AND ORTHODONTICS

    PATIENT CONSENT TO TREATMENT

    Check each box below and sign at the bottom.

















  • I UNDERSTAND THAT NO GUARANTEE OR ASSURANCE HAS BEEN GIVEN THAT THE PROPOSED TREATMENT WILL BE CURATIVE AND/OR SUCCESSFUL TO MY COMPLETE SATISFACTION. I AGREE TO COOPERATE COMPLETELY WITH THE RECOMMENDATIONS OF THE DOCTOR WHILE I AM UNDER HIS/HER CARE, REALIZING THAT ANY LACK OF SAME COULD RESULT IN LESS THAN OPTIMUM RESULTS

    I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE INCLUDING THE OPPOSING SIDE OF THIS DOCUMENT, AND CONSENT TO THE OPERATION AND EPLANATION REFERRED TO OR MADE. I HAVE BEEN ENCOUNTERED TO ASK QUESTIONS, AND HAVE HAD THEM ANSWERED TO MY SATISFACTION.

    I UNDERSTAND THAT DESERT SKY DENTAL AND ORTHODONTICS PROVIDES DENTAL CARE SERVICES WITHOUT DISCRIMINATION BASED ON RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION, PHYSICAL OR MENTAL DISABILITY, AGE OR MARITAL STATUS AND PROTECTS THE PRIVACY OF EACH OF IT’S PATIENTS

  • Parent or Legal Representative




  • Sierra Sky Dental

    5259 W. Indian School Rd.
    Suite 110
    Phoenix, AZ, 85031

    (623) 849-1000

  • Desert Sky Dental

    7620 W. Thomas Rd.
    Suite 102
    Phoenix, AZ 85033

    (602) 535-2682

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