The Dental Patient Release Form is an essential document used in Philippine dental practices to establish a clear understanding between dental professionals and patients regarding proposed treatments and associated risks. This document is required under Philippine healthcare regulations, particularly the Philippine Dental Act of 2007, and must comply with the Data Privacy Act of 2012. It should be completed before any significant dental procedure, containing comprehensive information about the patient's medical history, proposed treatment, potential risks, and financial obligations. The form serves multiple purposes: obtaining informed consent, documenting patient understanding, protecting the dental practice from liability, and ensuring compliance with healthcare regulations. It's particularly important in cases involving complex procedures, surgical interventions, or when specific risks need to be acknowledged by the patient.
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1. Patient Information: Basic patient details including name, contact information, age, and identification numbers
2. Medical History: Patient's relevant medical history, current medications, allergies, and previous dental procedures
3. Treatment Plan: Description of proposed dental procedures, expected outcomes, and alternative treatment options
4. Risks and Complications: Disclosure of potential risks, side effects, and complications associated with the dental procedures
5. Financial Agreement: Overview of treatment costs, payment terms, and insurance information
6. Consent Declaration: Patient's explicit consent to proceed with treatment and acknowledgment of understanding all disclosed information
7. Privacy Notice: Statement regarding the collection, use, and protection of patient information in compliance with the Data Privacy Act
8. Release of Liability: Legal statement releasing the dental practice from liability for disclosed risks and complications
9. Signatures: Spaces for patient/guardian signature, dentist signature, witness signature, and date
1. Guardian Authorization: Required when patient is a minor or lacks capacity to provide consent
2. Language Certification: Required when form is explained in a language other than English or Filipino
3. Emergency Contact: Optional section for emergency contact information
4. Photo/Video Release: Optional authorization for taking and using dental photos/videos for documentation or educational purposes
5. Insurance Assignment: Required when patient is using insurance coverage for treatment
1. Schedule A - Detailed Treatment Plan: Itemized list of specific procedures to be performed, including dental codes and estimated costs
2. Schedule B - Pre-operative Instructions: Detailed instructions for patient preparation before dental procedures
3. Schedule C - Post-operative Care: Instructions for post-procedure care and recovery
4. Appendix 1 - Patient Rights: Detailed explanation of patient rights under Philippine healthcare laws
5. Appendix 2 - Privacy Policy: Detailed privacy policy in compliance with the Data Privacy Act
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Dental Services
Medical Insurance
Healthcare Compliance
Medical Legal Services
Relevant Teams
Legal
Compliance
Medical Records
Patient Relations
Administrative
Clinical Operations
Insurance Processing
Risk Management
Relevant Roles
Dentist
Dental Surgeon
Dental Practice Manager
Healthcare Compliance Officer
Legal Counsel
Dental Assistant
Patient Relations Officer
Insurance Coordinator
Medical Records Officer
Dental Hygienist
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