POA & Guardian Consent Form | Luxury Tooth Booth Inc.

Complete this form with the patient whenever the patient has capacity to consent. If the patient lacks capacity, a legally authorized representative — such as a Medical Durable Power of Attorney agent or court-appointed legal guardian — must complete the applicable portions and sign below. Please provide authority documentation when requested.

Prefer to review this on paper first? Use Print a Copy at the bottom of the form, or reach us through the contact page and we will send a copy to you or to the patient's facility.

1. Patient Information

Patient's Full Legal Name *

Patient Date of Birth *

Patient Phone Number

Patient Email Address

Does the patient have the capacity to understand and consent to this care today? *

2. Authorized Representative / POA / Guardian

Complete this section if someone other than the patient will make healthcare decisions, sign consents, coordinate care, receive records, or receive financial communications.

Authorized Representative Full Name

Relationship to Patient

Representative Phone Number

Representative Email for SuperBills, Scheduling, and Updates

Representative Role / Authority

Authority Documentation Status

I represent that I am authorized to make healthcare decisions for the patient, or I am authorized by the patient to receive communications as indicated above. I will notify Luxury Tooth Booth Inc. if my authority changes, is revoked, or is limited.

3. In-Home / Facility Service Information

Facility Name, if applicable

Patient's Facility or Service Address

Apartment, Room, Unit, or Address Line 2

City

State

ZIP Code

Facility Telephone Number

Facility Contact Person and Title

Preferred On-Site Contact for Visit Coordination

4. Scope of Services

By signing this form, I authorize a licensed dental hygienist to provide preventive and palliative dental hygiene services that are clinically appropriate and permitted under applicable law, professional standards, and provider collaboration requirements.

Potential services may include:

Oral-health assessment and preventive dental hygiene care
Prophylaxis or periodontal maintenance, when clinically appropriate
Oral-hygiene education and individualized preventive recommendations
Antibacterial gum irrigation, when clinically appropriate
Intraoral photographs for clinical documentation, consultation, and care coordination
Dental X-rays when separately consented to and clinically indicated
Silver Diamine Fluoride (SDF) when separately consented to and clinically indicated
Teledentistry-supported consultation, documentation, and care coordination
Referral to a dentist, physician, emergency provider, or other appropriate provider when indicated

Important: I understand that Luxury Tooth Booth Inc. provides preventive and palliative dental hygiene services. These services do not replace restorative, surgical, emergency, or specialty dental treatment, including fillings, crowns, root-canal treatment, extractions, treatment of acute infection, or management of dental emergencies. I understand that the provider may determine that care cannot be safely completed in the home or facility setting and that referral may be necessary.

I understand and consent to the scope, limitations, and possible referral needs described above. *

5. Dental Photographs and X-Rays

I understand that photographs and dental radiographs/X-rays may be recommended when clinically appropriate to document findings, support treatment planning, facilitate consultation or referral, and monitor oral-health changes. I understand that declining recommended photographs or X-rays may limit assessment, documentation, treatment planning, and referral recommendations.

Clinical Photographs *

I authorize clinically necessary intraoral photographs for documentation, care coordination, consultation, and referral.

I decline intraoral photographs except when necessary for required clinical documentation.

Dental Radiographs / X-Rays *

I consent to clinically indicated dental radiographs/X-rays.

I decline dental radiographs/X-rays at this time and understand that this may limit assessment, documentation, treatment planning, and referral recommendations.

If X-rays are declined, reason or comments

6. Silver Diamine Fluoride (SDF) Consent

Silver Diamine Fluoride (SDF) is a topical liquid that may be used to help slow or arrest certain areas of dental decay. It is a non-restorative treatment option: it does not rebuild a tooth, restore lost tooth structure, or replace needed restorative dental treatment.

SDF may help slow or arrest active tooth decay when clinically appropriate.
SDF may permanently turn areas of active decay or weakened tooth structure dark brown or black.
Temporary staining of nearby skin, gums, lips, or other soft tissue may occur.
SDF may require repeat application based on clinical need, the patient's risk level, and provider recommendations.
SDF does not eliminate the potential need for restorative dental treatment, extraction, specialty consultation, or referral.
The provider may determine that SDF is not appropriate in a particular clinical situation.

Learn more about SDF: Review the American Dental Association's patient information page before making your choice: American Dental Association — Silver Diamine Fluoride (SDF).

I consent to SDF treatment if the provider determines it is clinically appropriate.

I decline SDF treatment at this time.

7. Teledentistry Consent

I understand that teledentistry may be used as part of the patient's dental care. A dentist or other appropriate provider may participate remotely through secure technology before, during, or after the appointment.

A dentist may be virtually present during the visit.
A complete diagnosis may not be available at the time of the appointment or immediately afterward.
Access to a dentist after the visit may be limited or asynchronous.
Clinical photographs, radiographs, video, and relevant health information may be securely transmitted through Teledentix or another appropriate platform for consultation, documentation, treatment planning, and care coordination.
Teledentistry may not be appropriate for every clinical situation, and the patient may be referred for an in-person dental, medical, specialty, urgent-care, or emergency evaluation.

I understand and consent to teledentistry-supported services and the secure transmission of relevant clinical information for these purposes. *

8. Privacy, HIPAA, and Communication Preferences

I understand that Luxury Tooth Booth Inc. will create and maintain records related to the patient's oral-health history, symptoms, examinations, clinical photographs, radiographs, services, recommendations, referrals, billing, SuperBills, and treatment planning. Protected health information may be used or disclosed as permitted or required by applicable law for treatment, payment, healthcare operations, care coordination, referrals, consultation, and legal or public-health obligations.

I acknowledge receipt of, or access to, Luxury Tooth Booth Inc.'s Notice of Privacy Practices. *

Preferred Communication Method

Email for SuperBills and Payment-Related Documentation

I authorize email and/or text communication for appointment scheduling, reminders, payment requests, SuperBill delivery, and general care updates.

I decline email and text communication and prefer telephone communication.

9. Collaborative Care and Information Sharing

I authorize Luxury Tooth Booth Inc. and the treating dental hygienist to share and exchange relevant patient health information with licensed healthcare professionals and authorized care team members involved in the patient's care, as reasonably necessary for care coordination and planning, medical-dental integration, continuity of treatment, referrals, consultations, second opinions, documentation, and payment-related processes.

Information shared may include clinical notes and treatment records, dental X-rays and intraoral photographs, relevant health history, medications, diagnoses, oral-health findings, recommendations, observations, referrals, treatment plans, and billing documentation.

If the patient has a legally authorized representative, I authorize Luxury Tooth Booth Inc. to include that representative in relevant care coordination, treatment discussions, scheduling, financial communications, and access to patient information within the representative's documented authority.

I understand that this authorization does not prohibit legally permitted or required communications, including disclosures required by law, emergency care needs, healthcare operations, payment activities, or communications the patient has directly authorized. This authorization remains in effect unless revoked in writing, except to the extent action has already been taken in reliance on it.

I authorize collaborative care communication and record-sharing for the purposes described above. *

10. Payment Agreement and SuperBill Policy

Luxury Tooth Booth Inc. may provide a SuperBill before or after each visit, including applicable dental procedure codes, for documentation and potential insurance reimbursement.
A SuperBill is not a claim submission and does not guarantee insurance coverage or reimbursement.
The patient, POA, guardian, or responsible party is responsible for confirming insurance coverage, submitting claims when applicable, and paying any amount not reimbursed by insurance.
A payment request may be sent through Zelle from a secure business account payable to Luxury Tooth Booth Inc., or through a secure Stripe payment link.
Unless another arrangement has been approved in writing by Luxury Tooth Booth Inc., payment is due before the scheduled appointment.
Services will not be rendered until required consent documents and payment have been received, unless a different written arrangement has been approved.

I understand and agree to the payment agreement and SuperBill policy. *

11. Final Consent and Electronic Signatures

By signing below, I confirm that I have read or had explained to me the information in this form, had an opportunity to ask questions and receive answers, and voluntarily consent to the services and authorizations selected above.

Name of Person Signing *

Signer Role *

Date Signed *

Electronic Signature *

By typing your full legal name, you intend to sign this form electronically.

Provider / Witness Name, if applicable

Required fields are marked with an asterisk.

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