Immediate/Permanent Denture Agreement of Acceptance

Patient Name*

First Last

Delivery and Seating of Temporary/Immediate Denture(s)

The signature of the patient or designated power of attorney below indicates:

My temporary denture(s) has/have been provided and placed in my mouth.

The provider has adjusted to meet my needs, and I accept delivery.

I understand that the healing process required to start treatment for my permanent dentures is approximately six months.

I also understand that if I do not return for treatment for my permanent dentures within 1 year of today's date, a price increase may be incurred to reflect the current prices of a permanent denture.

Patient/guardian/designated power of attorney signature*

DELIVERY AND SEATING OF PERMANENT DENTURE(S)

The signature of the patient or designated power of attorney below indicates:

My permanent denture(s) has/have been provided and placed in my mouth.

The provider has adjusted to meet my needs and I accept delivery.

I understand these are my final dentures.

Patient/guardian/designated power of attorney signature*

Phone

This field is for validation purposes and should be left unchanged.