Name
1. Treatment To Be Done
I understand that I am having the following work done:
Fillings
#
Bridge
#
Crown
#
Extraction
#
Impacted Teeth Removed
#
Root Canals
#
Other
#
2. drugs, Medications, And Sedation
I have been informed and understand that antibiotics, analgesic and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction) and they can cause pain, thrombophlebitis (inflammation of a vein from intravenous and intramuscular injections). Injury to and stiffening of neck and facial muscles. They may cause drowsiness and lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agreement not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of anesthetic, medication and drugs that may have been given me in the office for my care. I understand that failure to make medications prescribed for me in the manner prescribed may offer risk of continued infection and pain and potential resistance to effective treatment of my conditions.
Initials
3. Changes In Treatment Plan
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were have not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give permission to my Dentist to make any or all changes and additions necessary.
Initials
4. Removal Of Teeth
Alternatives to removal have been explained to me (root canal therapy, crowns and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth#
and any others necessary for reasons in paragraph III. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risk involved in having teeth removed, some of which are pain, swelling, and spread of infection, dry socket, numbness in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arises during or following treatment, the costs of which is my responsibility.
Initials
5. Crowns, Bridges, Inlays, Onlays, And Veneers
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize that the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size and color) will be before cementation. It has been explained to me that, in very few cases, cosmetic procedures may result in the need for future root canal treatment which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures. Tooth number#
Initials
6. Fillings
I have been advised for the need of fillings, either silver or composite (plastic), to replace tooth structure lost to decay. I understand with time fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post and build-up, and crowns), which would necessitate a separate charge.Tooth number#
Initials
7. Endodontic Treatment (root Canal Therapy)
I realize there is no guarantee that root canal treatment will save the tooth, and the complications can occur from the treatment and that occasionally metal objects are cemented in the tooth or extend through the root which does not necessary affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). Tooth number #
Initials
8. Periodontal Loss (tissue And Bone)
I understand that I have serious condition, causing and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment may have and have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.
Initials
I understand that I have serious condition, causing and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment may have and have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.
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