Horizon OMS — Surgical Consent

Horizon OMS of Chicago

Staff Access

Enter your 4-digit passcode

Create a free account at emailjs.com, add an Email Service, create a Template, then paste the IDs below. Saved to this browser.

Template variables: {{patient_name}} {{procedures}} {{teeth}} {{proc_date}} {{dob}} {{anesthesia}} {{witness}} {{consent_time}}

Public Key Service ID Template ID

Horizon OMS of Chicago

Surgical Informed Consent

6 E St. Charles Rd, Lombard IL 60148
P: (630) 425-2555 | F: (630) 425-2554
Dr. Ali Al-Qudsi, DMD, FAAOMS, ABOMS

01Patient

02Procedures

03Review & Mark Up

04Sign

Patient full legal name

Date of birth

Provider

Consent date:

Select one or more procedures

Step 1 of 4

Review, mark up & annotate

Select text → tap toolbar button. Draw mode (✍️): scribble with stylus or finger.

Mark up the consent as you discuss it with the patient. All markup prints with the document.

Patient signature

Sign with finger or stylus

Witness / staff signature

Staff — sign to witness

Relationship to patient

Witness / staff name

Consent date & time:

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