Prosthetic Consent
Please complete the information.
1. Personal information
Ime
Prezime
Date of birth
Contact phone
2. Prosthetic work information
Type of prosthetic work
Crown
Bridge
Denture
Implant restoration
Other
Material
Zirconia
Metal-ceramic
Acrylic
Other
Estimated number of visits
Notes
3. Voluntary Patient Consent
The patient has been informed about the prosthetic treatment plan, the chosen material, the estimated number of visits, and possible adjustments during fabrication. The patient agrees with the proposed plan and voluntarily consents to the described prosthetic treatment.
I agree with the stated terms and voluntarily consent to the prosthetic treatment
Patient signature
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