This agreement is entered into between “Patient,” hereinafter referred to as the “Patient,” and Teeth Hub Dental Clinic, represented by “Dental Provider,” hereinafter referred to as the “Dental Provider,” on “Date”.
- Purpose: The Patient seeks cosmetic dental treatment for the placement of veneers to improve the appearance of their teeth.
- Services: The Dental Provider agrees to perform the following services:
- Examination and assessment of the Patient’s dental condition.
- Custom design, fabrication, and placement of dental veneers.
- Necessary consultations and follow-up appointments related to the veneers.
- Treatment Plan: The Dental Provider will discuss and finalize a treatment plan with the Patient, including the number of veneers, materials to be used, and any preparatory procedures required.
- Risks and Limitations: The Patient acknowledges that while veneers are a widely accepted cosmetic dental procedure, there are inherent risks and limitations associated with the treatment. The Dental Provider will explain these risks, which may include but are not limited to:
- Potential for minor adjustments post-placement
- Sensitivity or discomfort initially after placement
- Risk of veneer damage over time due to habits like teeth grinding
- Cost and Payment: The total cost for the Veneers procedure is __________. Payment terms and schedule will be discussed and agreed upon by both parties before the commencement of the treatment.
- Consent and Authorization: The Patient acknowledges and consents to the placement of veneers as part of their dental treatment plan. They authorize the Dental Provider and their team to perform the necessary procedures outlined in the treatment plan.
- Cancellation and Rescheduling: In the event of cancellation or rescheduling of appointments, the Patient agrees to provide reasonable notice to the Dental Provider. The Dental Provider will also make every effort to accommodate necessary changes in the schedule.
- Post-Treatment Care: The Dental Provider will provide the Patient with instructions for post-veneer placement care. The Patient agrees to follow these instructions diligently to ensure proper healing and maintenance of the veneers.
- Dispute Resolution: Any disputes arising from this agreement will be resolved through negotiation and, if necessary, mediation in good faith between both parties.
- Governing Law: This agreement shall be governed by and construed in accordance with the laws of Philippines.
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