I UNDERSTAND that porcelain veneer treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (Even though care and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or desired results nor the longevity of the treatment).

1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of porcelain veneers, it is necessary to slightly reduce or roughen the surface of the tooth to which the veneer(s) may be bonded. This preparation will be done as conservatively as possible. If the veneer covering breaks or comes off, the uncovered tooth may become more decay susceptible. The tooth may require replacement with another veneer or crown.

2. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. At times root canal treatment will be necessary to remediate this situation.

3. Chipping, breaking or loosening of the veneer: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which the doctor has no control.

4. Esthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of veneers which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences which may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition.

5. Longevity: it is impossible to place any specific time criteria on the length of time that veneers should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both.

INFORMED CONSENT: I have been given the opportunity to ask any and all questions regarding the nature and purpose of porcelain veneer treatment and have received all answers to my satisfaction. I voluntarily assume any and all possible risks, including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved.

No guarantees or promises have been made to me concerning the results. The fee(s) for these services have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize my Doctor to render any treatment deemed necessary, desirable, and/or advisable to me, including the administration and/or prescribing of any anesthetics and/or medications.