The Release of Liability Form for Dental Treatment is a crucial document used in Canadian dental practices to establish a clear understanding between dental healthcare providers and patients regarding treatment risks and liability limitations. This document becomes necessary before performing dental procedures to ensure that patients are fully informed of potential risks and complications, and to protect dental practitioners from liability claims related to known and disclosed risks. The form must comply with provincial healthcare regulations, including specific requirements for informed consent under various Provincial Health Acts and professional dental regulatory bodies. It serves as both a risk management tool and a patient education document, helping to maintain transparent communication while providing legal protection for the dental practice.
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1. Parties: Identification of the dental practice, treating dentist(s), and patient (including contact details and health card number)
2. Background: Brief context explaining the purpose of the release form and its relationship to dental treatment
3. Definitions: Clear definitions of key terms used in the document, including 'Treatment', 'Liability', 'Informed Consent', and 'Healthcare Providers'
4. Acknowledgment of Treatment: Description of the dental treatment(s) to be performed and acknowledgment that they have been explained
5. Risks and Complications: Detailed outline of potential risks, side effects, and complications associated with the dental treatment
6. Voluntary Consent: Statement confirming that the patient is voluntarily consenting to the treatment and understands the risks
7. Release of Liability: The core waiver language releasing the dental practice from liability for known risks and complications
8. Emergency Authorization: Authorization for emergency treatment if necessary during the procedure
9. Integration and Severability: Statement that the document represents the entire agreement and severability clause
10. Governing Law: Specification that the agreement is governed by Canadian law and the relevant provincial jurisdiction
1. Specific Treatment Risks: Additional section for specific high-risk procedures requiring extra acknowledgment
2. Language Confirmation: For regions with multiple official languages, confirmation that the patient understands the language of the document
3. Pregnancy Declaration: For female patients of childbearing age, particularly relevant for procedures involving x-rays
4. Photo/Video Consent: Optional consent for taking photos or videos for dental records or educational purposes
5. Insurance Declaration: Statement regarding insurance coverage and patient's financial responsibility
6. Medical History Update: Confirmation that medical history is current and accurate
7. COVID-19 Acknowledgment: Additional risks and protocols related to treatment during pandemic conditions
1. Schedule A - Procedure Details: Detailed description of the specific dental procedure(s) to be performed
2. Schedule B - Risk Disclosure: Comprehensive list of potential risks and complications specific to the treatment
3. Schedule C - Post-Treatment Care: Instructions for post-treatment care and what to do in case of complications
4. Schedule D - Fee Schedule: Breakdown of treatment costs and payment terms if applicable
5. Appendix 1 - Medical History Form: Standard medical history questionnaire
6. Appendix 2 - Emergency Contacts: Patient's emergency contact information
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Healthcare
Dental Services
Medical Services
Insurance
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Healthcare Education
Medical Device Manufacturing
Pharmaceutical
Relevant Teams
Legal
Compliance
Risk Management
Patient Care
Administrative
Clinical Operations
Quality Assurance
Insurance Coordination
Front Office
Records Management
Relevant Roles
Dentist
Dental Surgeon
Orthodontist
Periodontist
Dental Hygienist
Dental Practice Manager
Healthcare Administrator
Legal Counsel
Compliance Officer
Risk Manager
Insurance Coordinator
Patient Care Coordinator
Office Manager
Healthcare Quality Manager
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