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Oral Treatment Acceptance Form

This is an oral treatment acceptance form that provides your patients with the treatment terms and price and asks for their acceptance.

Page 1

Please review the following treatment terms and price and indicate your acceptance below.

Email*

Patient Name*

Date of Birth*

Treatment Plan*

Treatment Description*

Treatment Price*

Description:Use this oral treatment acceptance form to provide your patients with the treatment terms and price and ask for their acceptance. This customizable form template is easy to use and can be tailored to your practice's needs.

Ensure your patients are fully informed and agree to the terms of their oral treatment with this acceptance form. Simply fill in the treatment details and price, and ask your patient to sign and date the form. This form can be customized to include your practice's logo and contact information. By using this form, you can ensure that your patients are aware of the treatment they will receive and the associated costs, helping to avoid any misunderstandings or disputes later on. Use this oral treatment acceptance form to streamline your patient intake process and provide a professional and efficient service.

Company Name*

Contact Person*

Phone Number*

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Date of Birth*

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First Name*

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