1. Work to be done I understand that I am having the following treatments: □ Cleanings □ Fillings □ Periodontics □ Root canals □ Extractions □ Crown □ Dentures
2. Changes in Treatment Plan I understand that during treatment it may be necessary to change procedures because of conditions found while working on the teeth that were not discovered during examination. I give my permission to the Dentists to make those changes as necessary.
3. Medications, Cleaning, and Filling Materials I understand that antibiotics, analgesics, other medications and/or dental materials can cause allergic reactions causing swelling, pain, vomiting, and/or breathing difficulties. I have been told to take a Dental Material Fact Sheet and the HIPAA Notice of Privacy Practices and they are provided.
4. Anesthesia I realize the risks involved in receiving a local anesthetic, some of which include: bruising, vision impairment, partial facial paralysis, hemorrhage, nerve damage with numbness, itching, and/or pain, inflamed tissue, adverse reactions to drugs causing cardiac arrest or miscarriage.
5. Periodontal Loss (Tissue and Bone) I understand that I have a serious condition, causing gum and bone inflammation or loss that it can lead to the loss of my teeth. The alternative treatment plans have been explained to me, including gum surgery, replacements or extractions. I recognize that if I refuse any of the treatment for this conditions, I am jeopardizing the longevity of my dentition (teeth) the dental treatment which I am having done.
6. Refusal of Periodontal Specialty Referral I understand that I have periodontal (gum) disease and that if untreated that condition may worsen and lead to further bone loss and premature tooth loss. I have also been informed of the benefits of treatment and available alternatives. I voluntarily refuse a referral to a periodontist (gum specialist).
7. Removal of Teeth Alternatives to removal have been explained to me (root canal therapy, crowns and periodontal surgery,) and I authorize the Dentists to remove the teeth listed in my treatment plan and any others necessary under paragraph #3. I understand the risk involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, fractured jaw, broken fillings, broken crowns, and/or loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (usually days or months, but occasionally permanent). I understand I may need further treatment by a specialist and hospitalization if indications arise during or following treatment, and the cost for such treatment is my responsibility.
8. Dentures – Complete or Partial I realize that full or partial dentures are artificial, constructed of plastic, acrylic, metal, and/or lain. The problems of wearing these appliances have been explained to me including looseness, soreness, and possible breakage, and for periodic relining due to tissue and bone change. Dentures delivered following extractions will require additional relines during and at my expense.
9. Endodontic Treatment (Root Canal) I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment. Occasionally metal objects are cemented in the tooth which does not necessarily affect the completeness of the treatment. This treatment often requires multiple visits. I can cause serious damage or loss of the tooth/teeth involved if I do complete the prescribed treatment including a final restoration. I accept that further treatments may be diagnosed in the future.
10. Crown, 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, and that if I don’t have the permanent crowns placed permanent serious damage or loss of teeth involved may ensue, and that if I delay placement I may cause the teeth involved to move so that the permanent crowns no longer fit properly.
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I hereby request and authorize the Dentists, and their Staff, to perform dental work upon me for the purpose of attempting to improve my appearance, function and the health of my mouth, teeth, bone and tissues, as explained above and presented in the treatment plan. I understand that specialty care may be recommended to complete these procedures and accept the financial costs.
I understand that the practice of Dentistry and surgery is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I recognize that complications and stresses involved in dental treatment pose the remote possibility of leading to the loss of life.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO DENTAL TREATMENT AND THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE. ANYTHING I DID NOT UNDERSTAND HAS BEEN EXPLAINED TO ME.