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Great Value Pet Clinic, LLC 11580 Black Forest Rd, Unit 10 Colorado Springs, CO 80908 Phone: 7196463580 Fax: 719 6299183 greatvaluepetclinic@yahoo.comDental Prophy Release Form Client: ___ Patient:
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How to fill out dental prophy release form
How to fill out dental prophy release form
01
Obtain the dental prophy release form from the dental office or website.
02
Fill out your personal information including name, address, contact details, and date of birth.
03
Provide details of your dental insurance including policy number and provider.
04
Answer any medical history questions accurately and completely.
05
Sign and date the form to certify that all information provided is accurate and complete.
Who needs dental prophy release form?
01
Anyone undergoing a dental prophylaxis (cleaning) procedure at a dental office may be required to fill out a dental prophy release form.
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What is dental prophy release form?
A dental prophy release form is a document signed by a patient that allows their dental provider to perform a dental prophylaxis, commonly known as a dental cleaning.
Who is required to file dental prophy release form?
Any patient receiving a dental prophylaxis is required to sign a dental prophy release form.
How to fill out dental prophy release form?
To fill out a dental prophy release form, the patient must provide their personal information, sign the form, and indicate any allergies or medical conditions.
What is the purpose of dental prophy release form?
The purpose of a dental prophy release form is to ensure that the patient understands and consents to the dental cleaning procedure, as well as to disclose any medical information relevant to the treatment.
What information must be reported on dental prophy release form?
The dental prophy release form must include the patient's name, contact information, medical history, allergies, and consent to the dental prophylaxis.
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