I hereby authorize Dr. Brian P. Ganley, DMD Family Dentistry to take radiographs, study models, photographs, or any
other diagnostic aids Dr. Brian P. Ganley, DMD Family Dentistry deems appropriate to make a thorough diagnosis of my
dental needs. I also authorize Dr. Brian P. Ganley, DMD Family Dentistry to perform any and all forms of treatment,
medication, and therapy that may be indicated, including, but not limited to examinations, local anesthetic*,
restorative, and preventive treatment. I authorize and consent that Dr. Brian P. Ganley, DMD Family Dentistry
employs any such assistance as they deem appropriate.
*DRUGS AND MEDICATIONS I understand that I may receive a local anesthetic and/or other medication. In rare instances,
patients may have a severe reaction to the anesthetic, which may require emergency medical attention, or find that
it reduces their ability to control swallowing. This increases the chance of swallowing or aspirating foreign
objects during treatment. Depending on the anesthesia and medications administered, I may need a designated driver
to take me home. Rarely, temporary or permanent nerve injury can result from an injection.
I further authorize the release of any information, including the diagnosis, radiographs, and records of any
treatments or examinations rendered to my insurance company, consulting professionals, or others that may request my
records.
I understand that I am personally responsible for payment of all fees for dental services provided in this office
for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of
compensating the practice for any related attorneys and collection fees. I understand that payment is due when
services are rendered. Any other arrangements for payment must be made before treatment begins.
This general informed consent may remain in effect until treatment is terminated either by Dr. Brian P. Ganley, DMD
Family Dentistry and/or the patient and the patient is no longer regarded as a patient of record.
I confirm that I understand this form and the information contained therein. I am a native speaker of English or
have been offered the services of a qualified translator who has explained the information in my native tongue.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
