Office Policy for S. Robert Davidoff

Informed Consent Regarding Observers and Teaching Situations

From time to time, there may be one or more observers or observer/assistants viewing your dental

procedures. These observers are all licensed dentists who are in the process of completing certain

training requirements with Davidoff Dental Seminars, Inc.. Davidoff Dental Seminars, Inc is approved by the State of Florida and the American Dental Association as a provider of continuing Dental Education. Your dental treatment may also be photographed and video-recorded. This document is provided for your information and protection. Please read carefully and sign and date at the bottom.

1. All actual dental work will be performed by Dr. Davidoff.

2. Dr. Davidoff will make all treatment decisions with your informed consent.

3. The observers may function in the capacity of a dental assistant.

4. All observers are licensed dentists and have the proper liability insurance coverage.

5. Some discussion about your treatment might occur during these sessions. The discussion is aimed at informing the observer.

6. If you have any objection to someone observing your dental procedures, please initial here ___________ Arrangements will be made to exclude you from any course material.

7. Photos and video will be used for educational purposes only.

8. Please do not hesitate to ask any additional questions about your dental treatment and the functioning of Davidoff Dental Seminars, Inc..

If you agree to allow other dentists and staff to observe and assist in your dental procedures and you also agree to allow us to photograph or video these procedures for educational purposes, Please sign below.

_____________________________________ _____________________________

Signature Date