Common Contracts
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The University of Texas Health Science Center at San Antonio Dental School CONSENT AND AGREEMENT FOR TREATMENTFebruary 23rd, 2009
Please read the following information carefully. After you have read this Consent andAgreement, please sign your name below to accept the terms of this agreement. 1. Consent to treat: As a consenting adult, I agree to permit the students, faculty, staff and residents of The University of Texas Health Science Center at San Antonio Dental School (UTHSCSA‐DS) to provide dental care to myself, my child or patient representative as applicable. 2. Teaching facility: As a patient of UTHSCSA‐DS, all treatment will be provided by faculty or by students or residents of the Dental School under the supervision of clinical faculty. 3. Limitations: Not all persons can be accepted as patients of UTHSCSA‐DS. Persons with complicated medical conditions, rigid time requirements, and extremely difficult dental care needs may not be accepted. I understand that if I am accepted as a patient, my treatment at the UTHSCSA‐DS may be limited, after which time I would need to find dental care outside the Dental
