Dental Services Consent

A registered dentist will be visiting the nursing home to provide dental assessments and
treatment to residents who wish to avail of the service.
Dental care may include, but is not limited to:

•  Oral examinations
•  Denture assessments and adjustments
•  Preventive dental care
•  Emergency or urgent dental treatment
•  Other necessary dental procedures as deemed appropriate by the dentist

All treatment will be carried out in accordance with professional dental standards and with
the resident’s best interests in mind.

Medical Information

Please provide any relevant medical information that the dentist should be aware of:

Consent Declaration

I confirm that:

• I am the resident named above OR I am the resident’s next of kin / legal
  representative.
•  I understand the nature of the dental services being provided within the nursing
  home.
•  I consent to the dentist carrying out dental examinations and any necessary
  treatment.
•  I understand that not all treatment may be covered by a Medical Card and that
  private fees may apply where relevant. A private price list has been made available.
• I understand that consent may be withdrawn at any time.

Authorisation