Consent Video & Form: Crown Placement

SMED Crown Placement Consent Documentation

Name *

Name

First Name

Last Name

Please re-enter the following in the box below: *

"I have watched and heard the SMED crown placement consent video and am giving my consent to be operated on"

Initials (first and last) *

By entering your initials, you are validating the statement above that you have agreed to consent and have watched the video

Date: *

(mm/dd/yyyy)