1. WORK TO BE DONE: I understand this consent covers routine examination, x rays, cleanings, fluoride, and restorative treatment such as fillings, crowns, sealants, and root canals that may be recommended during my care at this practice. Extractions and any other procedure identified as needing separate authorization are covered by a separate consent, completed at the time that treatment is recommended.
2. DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications could cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock.
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. For example, root canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions as necessary.
4. LIMITED REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.) I understand that if extraction is recommended, the dentist will identify the specific tooth or teeth involved and discuss the specific risks with me before any tooth is removed, and that discussion will be documented in my chart. 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 (paresthesia) that can last for an indefinite period of time, or fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility. I understand that surgical or impacted tooth removal carries higher risk than simple extraction, including longer healing time, greater likelihood of swelling or bruising, sinus involvement for upper teeth, and increased risk of nerve related complications.
5. CROWNS, BRIDGES, AND CAPS: 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 the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, and color) will be before cementation. It is also my responsibility to return for permanent cementation within 21 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown, bridge, or cap. I understand that there will be additional charges for remakes due to my delaying permanent cementation.
6. LIMITED ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee that root canal therapy will save my tooth, and that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files are very fine instruments and stresses from their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts to save it.
7. PERIODONTAL LOSS (TISSUE AND BONE): I understand that I have a serious condition, causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedure may have a future adverse effect on my periodontal condition.
8. FILLINGS: I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling.

Consent for 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 even though care and diligence will be exercised by the dentist while rendering this treatment, including possible unsuccessful results, temporary tissue irritation from the etching process, loosening or dislodging of the sealant over time, and the fact that sealants do not protect the areas between teeth, so thorough brushing and flossing remain necessary.

Consent for Amalgam (Silver Filling) Restoration: With regard to any silver fillings that are still in good working condition, I acknowledge that it is my own choice to replace them with composite (tooth colored) fillings and that my dentist has not advised me that they need to be replaced for any health issue in the absence of an allergic condition. I understand there is no generally accepted scientific proof that replacement of silver fillings with composite fillings will improve my health. I understand this is an elective procedure and that other options, including no treatment at all, are available and have been discussed with me. Risks include nerve inflammation leading to hot and cold sensitivity or pain, the need for root canal treatment, cracked cusps, and a shorter length of serviceability of the restoration with the need for more frequent replacement. It has been explained to me that during the course of treatment, unforeseen conditions may be revealed that may necessitate an extension of the original procedure or a different procedure than described above, and I authorize and request that the dentist perform such procedures as are medically necessary and desirable in the exercise of professional judgment.

I consent to the administration of local anesthesia in connection with the procedure(s) referred to above, as may be advisable, with the exception of ______________, to which I am allergic. I recognize that there are always risks to life and health associated with anesthesia and such risks have been fully explained to me.

Consent for Composite (Tooth Colored) Fillings: I understand that the placement of composite resin fillings, which may be more aesthetic in appearance than conventional materials such as silver amalgam or gold, may entail certain risks, and I agree to assume those risks even though care and diligence is exercised by my treating dentist. Risks include possible sensitivity of the teeth after preparation, small fracture lines in the tooth structure that may appear at a later time, possible need for root canal treatment if the pulp is affected, temporary or, rarely, permanent numbness from injury to nerves, imperfect or changing color match over time, and possible breakage, dislodgement, or bond failure due to chewing pressure or other traumatic forces.

I understand that dentistry is not an exact science and that reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I hereby authorize the doctors and dental auxiliaries of this practice to proceed with and perform the dental restorations and treatments explained to me. I understand that any estimate given is subject to modification depending on unforeseen or undiagnosable circumstances that may arise during treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of the dental fees.

I am aware that alternative treatments/procedures may be available, as well as the option not to proceed with the recommended treatment/procedure. I also understand that there are inherent risks to this recommended treatment/procedure as well as to any alternate treatment/procedure, and to postponing or declining this recommended treatment/procedure.

My dentist or their staff has offered me a more detailed explanation of this recommended treatment/procedure if I so desire. I am fully satisfied with the description and information given, and all my questions/concerns have been satisfactorily answered. I acknowledge that no guarantee or warranty has been made to me about the results of any of the above recommended choices. Therefore, I freely give my consent to the above recommended treatment/procedure.