I acknowledge that I am having a Night Guard made by West Grande Prairie Dental. I certify that the dentist that examined me has fully explained to me the purpose of the procedure(s) and has also informed me of the expected benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise, as well as possible alternatives to the purposed treatment, including no treatment.

The attendant risks of no treatment have also been discussed.

I certify that the dentist who examined me has explained post treatment instructions (how to use the nightguard and place it each evening) and I have been informed I can ask any questions following treatment at any time. I have chosen to have an (please checkmark) Night Guard made.

I have been given an opportunity to ask questions and all my questions have been answered fully and satisfactorily.

I have been given the opportunity to delay my decision/treatment and/or seek a second opinion I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the procedure(s) which West Grande Prairie Dental may consider necessary.

I acknowledge that no guarantees or assurances have been made to me about how long the retainer will last and that if it breaks or is damaged there will be a charge made for a replacement. I am aware the warranty for this product is limited to 1 year past the manufacturing date. I also understand the financial obligation attached to this procedure carried out today and agree to comply as listed below.

Total amount if not covered by insurance would be $641.10 (Subject to change)

I understand that I am responsible for all fees not covered by my insurance. I confirm that I have read and fully understand the above and that all blank spaces have been completed prior to my signing. I realize that signing does not mean that I am under an obligation to have any treatment and that I may decide not to proceed with all or any part of the treatment. Similarly signing this means that I only pay for the treatment that I have had completed. I hereby consent to the proposed Nightguard.