Here’s one that i have used over the years:

Consent and Authorization for Treatment with the Dental Laser

1.I understand that Dental Lasers marketed and sold in the United States have been cleared for marketing by the Food and Drug Administration (FDA) for use in dentistry.

2.I understand that Doctor __________ and Doctor __________ have been trained extensively in the use of Dental Lasers by the best universities, academies and experts that teach this information.

3.I have been presented with the laser treatment plan and fees-for-treatment. I have been informed of other methods of treatment and the alternatives. The expected results and risks (even the remote chance of death) of the proposed treatment (and/or no treatment) have been explained to me.

4.I understand there is no guarantee of success or permanence of the treatment.

5.I understand that dental conditions in my mouth can change and alter the proposed treatment plan.

6.I understand that any time teeth are manipulated, whether by a mechanical drill or laser, there is always the possibility and risk that Root Canal Therapy may be necessary. I realize that in spite of the observation of every reasonable precaution — prior nerve damage, infection, or tooth trauma may have pre-existed in the tooth.

7.I understand that anytime that soft tissue is manipulated, whether by traditional dental technology, or laser dentistry, there is always a possibility and risk of unexpected and undesirable side effects.

8.I understand that “high technology” dentistry, including laser therapy, may be considered “investigational” or “experimental” and may not be reimbursed by some insurance companies, and I must anticipate paying 100% of any such treatment.

9.I have read and agreed to the foregoing. I have had the opportunity to ask treatment related questions and have been advised of the risks and benefits of treatment, including the use of local anesthesia and dental lasers.

11.I, ______________________________________, authorize the performance, upon myself, of dental treatment using dental lasers, which treatment will be performed by Robert H. Gregg, D.D.S. or Delwin K. McCarthy, D.D.S.

Patient Signature, _________________________________________________Date, _______________

Witness, ________________________________________________

Glenn–Why…..thank you…….thank you very much (in my best Elvis voice), now that’ll be &#3650 bucks:biggrin:

I appreciate the kind words, and always happy to share whatever I can.  Glad you like it!  You and any clinician have my blessings for their personal use of it.

Manufacturers and lecturers should use with permission and acknowledgement–that has not always been the case, unfortunately.

2thdoc–

I really depends on what procedure you are actually performing, not the device. If you are performing a “curettage” procedure and regardless of whether you are using steel or laser, the you would bill for that.

Remember that there are ADA/CDT “procedure” codes, and the various carriers and their individual “payment” codes. They are often, but not always the same.

For example, many carriers do NOT have a payment code for 4240–Mucogingival Surgery per quadrant, so if you bill that out, you will get a DENIAL not an explanation.

The best way to answer the question is to better understand what procedure(s) you are performing?

Bob