Please read sign at the bottom of the next page.
1. X-Rays: I understand that dental radiographs (x-rays) are taken as part of a complete and thorough exam, in order to assist in diagnosisng oral or dental disease that may be present. I authorize that all needed x-rays can be taken.
2.DRUGS, MEDICATIONS & ANESTHESIA: I understand that antibiotics and analgesics and other medications may cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction I understand that occasionally upon injection of a local anesthetic, I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection.
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 not discovered during examination, the most common being root canal therapy following routine restorative procedures. I have my permission to the Dentist to make any/all changes and additions as necessary.
4.FILLINGS: I have been advised of the need for fillings to replace tooth structure lost to decay. I understand that with time fillings will need to be replaced due to wearing of material. I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. In cases where decay enters nerve, 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 crown) which would necessitate a separate charge. I understand that significant sensitivity is a common after effect of a newly placed filling.
5.SEALANTS: I understand that the treatment of teeth through the use of sealants is a preventative measure intended to facilitate the inhibition of dental caries (tooth decay or cavities) in the pits and fissures of the chewing surfaces of the teeth. Sealants are placed with the intention of preventing or delaying conventional restorative measures used in restoring teeth with fillings or crowns after the onset of dental caries . I agree to assume any risks that may be associated with the placement of sealants. In addition to possible unsuccessful results and failure of the sealant may require replacement.
6.CROWNS, BRIDGES 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 crows, 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 understand that at times during the preparation of a tooth for a crown pulp exposure may occur, necessitating possible root canal therapy. I also understand that like natural teeth, crowns, bridges and veneers need to be kept clean with proper oral hygiene and periodic cleanings, otherwise decay may develop underneath and/or around the margins of the restoration, leading to further dental treatment. I realize the final opportunity to make change in my new crown; bridge or cap (including shape, fit, size and color) will be before cementation.
7.GUM DISEASE/PERIODONTAL LOSS (TISSUE & BONE): I understand that I have a serious condition causing gum and/or bone inflammation and/or bone loss and that can lead to loss of my teeth and other complications. The various treatment plans have been explained to me, and although these treatments have a high degree of success, they cannot be guaranteed. Occasionally, treated teeth may require extraction. I understand that the long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e. brushing and flossing) and maintaining regular recall visits.
8.REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc when applicable and I authorize the removal by Dr. Volluz. 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 risks involved in having teeth removed, some of which are pain, swelling spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue parasthesia that can last for an indefinite period of time days or months or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization of complications arise during or following treatment, the cost of which in my responsibility.
9.DENTURES, COMPLETE OR PARTIAL: I realize that full or partial dentures are artificial, constructed of plastic, metal and /or porcelain. The problems of wearing these appliances have been explained to me, including looseness soreness and possible breakage. I realize the final opportunity to make changes in my new dentures including shapes, fit, size, placement and color will be the teeth in wax try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost of this procedure is not included in the initial denture fee. I understand the wearing of dentures is difficult. Sore spots, altered speech and difficulty in eating are very common problems. Immediate dentures placement of dentures immediately after extractions may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitting dentures. If a remake is required due to my delays of more than 30 days there will be additional changes, which is my financial responsibility.