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I, the undersigned, do hereby state and confirm as follows:
Additionally, it is important to be aware of your insurance coverage. I understand that my HMO insurance may not cover treatments for moderate to severe calculus deposits or stain removal, and I am responsible for any associated costs.
Please remember to consult with your dental professional and insurance provider to obtain accurate information regarding your specific insurance coverage and potential out-of-pocket expenses.
I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment.
I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
I understand that due to the type of lesion I have, my dentist has recommended that I undergo a biopsy, which is a procedure in which a portion of the lesion will be removed. The expected result of this procedure is to adequately diagnose the lesion type.
I understand that there are risks and complications associated with this procedure, which include but are not limited to infection, need for another biopsy to be performed, and scarring.
Understanding all of the above, I request that and hereby provide my informed consent to the treating doctor and his/her assistants to perform a biopsy. I understand that in the course of the biopsy it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the treating doctor to perform such procedures at his/her discretion if needed during my biopsy.
I consent to having local anesthesia. I understand the performance of diagnostic studies relating to my biopsy will be performed by other medical/dental professionals.
I confirm with my signature that:
• My dentist has discussed the above information with me.
• I have had the chance to ask questions.
• All of my questions have been answered to my satisfaction.
• I do hereby consent to the treatment described in this form.
I confirm with my signature that I have discussed with the above-named patient the risks, potential complications, and intended benefits of the biopsy, as well as alternatives. The patient has had the opportunity to ask questions, all questions have been answered, and the patient has expressed understanding. Thus informed, the patient has requested that I perform a biopsy upon him/her.
This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching") of my teeth.
Risks of Consent for Treatment
I understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all-natural teeth structure can benefit from whitening treatments and significant whitening can be achieved in most cases. I understand that whitening is not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently receive better results than people with gray/bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches, or spots due to tetracycline use/fluorosis do not whiten as well, may need multiple treatments/may not whiten at all. I understand that Provisionals/temporaries made from acrylics may become discolored after exposure to whitening treatments.
I understand that whitening is not recommended for pregnant/lactating women, light sensitive individuals, patients receiving PUVA (psoralen + UVA radiation) or other photo chemo-therapeutic drugs/treatment, as well as patients with melanoma, diabetes, or heart conditions. I understand that the ZOOM/Laser light emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing any whitening treatment
I understand that the results of my Whitening treatment cannot be guaranteed.
I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the whitening systems, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:
I understand that my dentist has evaluated whether I am a proper candidate for an in house whitening procedure. The dentist can explain the safety, efficiency, potential complications, and risks of whitening to me, and I understand that more information on this will be available upon my request. Since it is impossible to state every complication that may occur because of whitening, the list of complication on this form is incomplete.
In signing this consent form, I am stating I have read this informed consent (or it has been read to me) and I fully understand it and possible complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by the dentist.
1. For the dental procedure you are to undergo, sedation and analgesic medications may be used. The benefit of sedative and analgesic medication is to allow the safe, comfortable completion of your dental treatment. I understand that the anesthetics/ sedative drugs and physical restraints are necessary to assist the dentist in performing the dental treatment with increased patient comfort and cooperation.
2. I have been informed and understand that there are associated risks with the use of local anesthetic agents and sedative drugs used to increase the patient comfort and to control patient veins used for administering the drugs; discoloration of the tissue surrounding the injection site, swelling, infection, bleeding, nausea, vomiting, and allergic reaction. The primary risk of these medications is respiratory depression (decreased breathing effort), which can be serious or even fatal if not treated. This risk is minimized by careful administration of these medications and by the vigilant monitoring of my blood pressure, heart rate and breathing.
3. Infrequently, allergic reactions to medications can occur. I have been informed to advise the dentist of any known allergies to any medications or have any concerns about receiving sedation/analgesia.
4. I have been informed and understand that in rare instances, the risk of a sedative drugs include but are not limited: breathing difficulties; brain damage; stroke; heart attack; or loss of function of any limb or body organ. I understand that severe complication may require hospitalization and may even result in death.
5. The purpose and possible complications to the used sedative drugs have been explained to me as well as possible alternative methods and their advantages and disadvantages. I understand the purpose, possible risks, and probable effectiveness of each method approach to treatment as well as the probable result if no treatment is provided.
6. I have been advised that good results are expected and that the possibility and exact nature of complications cannot be accurately predicted. I acknowledge that no implied or expressed guarantees as to the result of the treatment or use of anesthetic or sedative drugs have been given to me.
7. I acknowledge that I have received written preoperative and postoperative instructions regarding the use of sedative drug that these instructions have been explained to me, and that understand this information.
8. I am aware that I may decline the administration of sedatives and analgesics or wish to discuss other alternatives, which include local anesthesia, and general anesthesia.
9. I have had the opportunity to ask of my questions and all my questions have been answered to my satisfaction. I believe I have been given adequate information upon which to base and informed consent.
I have read this consent and understand, to my satisfaction, the procedures to be performed and accept the possible risks. I consent to allow BrightSmile Avenue and its associates to administer, as appropriate the medications(s) required to complete this dental procedure.
I voluntarily consent to dental crowns and bridges (the differences which have been explained to me) and bonding. I further authorize you to use methods of treatment you may find necessary during the procedure which may have not been known to me before the procedure began. I have chosen veneers and bonding over the alternatives that have been explained to me.
The preparation has been fully explained to me, including the risks involved. I have been informed that complications might include, but are not limited to:
In addition, the consequences of non-treatment have been explained to me. I have had an opportunity to ask questions and am fully satisfied with the answers I have received. I have also been given instructions in care and maintenance regarding this procedure and agree to follow the instructions carefully.
I understand that oral surgery and/or dental extractions include inherent risks such as, but not limited to the following:
It is my responsibility to seek attention should any undue circumstances occur post-operatively and I shall diligently follow any pre-operative and post-operative instructions given to me.
Please read below carefully and ask for help if you need any clarifications or further information.
We appreciate your confidence in selecting our office for your orthodontic treatment. We want you to be fully informed and invite you to inquire about your treatment at any time.
As a rule, excellent orthodontic results can be achieved with informed and cooperative patients. Thus, the following information is supplied to anyone considering orthodontic treatment in the office. While recognizing the benefits of a pleasing smile and healthy teeth, you should also aware of the orthodontic treatment has some risk and limitations.
I have read and understand this letter of information and hereby give consent to the orthodontic treatment recommended by my dentist.
I request that my orthodontic appliances/brackets be removed on this date. I understand that I will not have the best achievable orthodontic result and accept the consequences of having my orthodontic appliances/ brackets be removed. I realized that leaving teeth in their current position may be a periodontal compromise or affect my temporo-mandibular joint. I understand that for teeth to remain in their current position, use of removal retainers is required. I also understand that I, upon the removal of the orthodontic appliance/ brackets, release the orthodontist, BrightSmile Avenue and its affiliates of any liability and responsibility. If I decide to continue orthodontic treatment later, then the decision as to whether to treat my case will be entirely up to the orthodontist. If considered, a full case fee will be charged.
Congratulations! Today is the day that your braces are coming off to unveil your beautiful smile! You are now entering an important phase of your treatment—the Retention Phase.
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Teeth have a memory and often try to move back to their original positions. Retainers are required to keep your teeth in their new positions. Regular retainer wear is necessary for lifetime as your body is continually undergoing growth and maturation. Minor irregularities, particularly in the lower front teeth may occur. In summary, you need your retainers to keep your teeth as straight as possible. But even with good retainer wear, your teeth may move slightly.
Retainer Instructions and Responsibilities
I understand that I have the following responsibilities:
1. Wear my removable retainers 22 hours a day (including sleeping) for the first year followed by “night-time for life-time” wear.
2. Do not wear my removable retainers during eating to prevent damage.
3. Keep my removable retainers in the proper case when not wearing them.
4. Maintain my scheduled retention appointments as prescribed by my orthodontist.
5. Bring all removable retainers to my retention appointments.
6. Clean around my bonded retainer.
7. Have my General Dentist evaluate the readiness for wisdom tooth extraction.
8. Call the office immediately if my retainer breaks or is not fitting properly.
Lost or Broken Retainers
Your retainers are made using only the best possible material. If a retainer is lost or damaged, call our office immediately to schedule an appointment. There will be a laboratory charge per replacement retainer.
If further treatment is required due to unexpected growth or noncompliant retainer wear, additional charges will be applied.
I understand the above information. I have had an opportunity to ask any questions and I have had those questions adequately answered.
Your Periodontist has made a diagnosis that you have periodontal disease and has made a recommendation that you require periodontal treatment. This document is designed to outline this treatment, its risks, expected outcomes, alternatives and your responsibilities.
Periodontal therapy includes conservative treatment, surgical treatment and periodontal maintenance. The treatment plan recommended to an individual patient may involve some or all of these types of periodontal treatment.
Conservative treatment involves comprehensive instruction in oral hygiene techniques, periodontal charting involving measurement of pocket depths and other clinical features and the use of hand and sonic instruments that are placed between the gum and tooth surfaces. These special instruments are used to remove bacterial bio film and infected gum tissue that accumulates over time on the root surfaces of teeth and in periodontal pockets. This treatment is also referred to as scaling and sub gingival debridement and may be carried out over several visits by your Periodontist, a Hygienist or both. In addition, administering local anaesthetic, antibiotics or antiseptics may form part of this treatment.
Surgical treatment involves administering local anaesthetic prior to cutting and opening up the gum to permit better access to the roots and to the eroded bone. Inflamed and infected gum tissue will be removed, and the root surfaces will be thoroughly cleaned. Bone irregularities may be reshaped and bone regenerative material may be placed around teeth. The gum will then be sutured back into position, and a periodontal bandage or dressing may be placed. The administering of antibiotics and antiseptics may form part of this treatment. Unforeseen conditions may call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, (1) extraction of hopeless teeth to enhance healing of adjacent teeth, (2) the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or (3) termination of the procedure prior to the completion of all of the surgery originally outlined.
Periodontal surgical treatment also involves the patient returning for follow up visits to check on healing. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of surgery. It is important that patients abide by the specific prescriptions and instructions given by the Periodontist or his/her staff after surgery.
The Expected Benefits of Treatment
It is expected that periodontal treatment will control periodontal disease to prevent potential loss of teeth in the future. It should also reduce or eliminate symptoms of the disease such as bad breath and bleeding of the gums when brushing and flossing. In addition, treatment may make oral hygiene techniques more effective and enable professionals to better clean the patient’s teeth.
The Principal Risks and Potential Complications
A small number of patients do not respond successfully to periodontal treatment. Due to individual patient differences there remains some risk of treatment failure, relapse, additional treatment, or even worsening of the present condition, including oss of certain teeth, despite the best of care.
There is no method that will accurately predict or evaluate how an individual’s gum and bone will heal. There may be a need for a second procedure if the initial results are not satisfactory. In addition, the success of periodontal procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene, and medications. It is the patient’s responsibility to disclose prior drug reactions, allergies, diseases, symptoms, habits, or conditions which might in any way relate to periodontal treatment.
If you elect not to have local anaesthetic during conservative periodontal treatment some discomfort (mild to moderate depending on your individual pain threshold) may be experienced. If local anaesthetic is used no discomfort should be experienced. However, care will be required for up to 4 hours following the procedure not to inadvertently cause damage to the numb area (either hot/cold or biting the lip). Some discomfort of the gum tissues is common following treatment. This is usually of very short term and controlled at worst with normal over-the-counter pain relievers. Increased sensitivity of the root surfaces to hot and cold is also common (this will resolve in most cases if the oral hygiene instruction you will be given is followed carefully). Rarely, an abscess may occur in the gum following treatment and our practice will treat this if it occurs promptly.
Complications may also result from periodontal surgery, drugs, or anaesthetics. The exact duration of any complications cannot be determined, and they may be irreversible. These complications include, but are not limited to:
Possible Alternatives to our Recommended Treatment
Similar treatment may be available within your general dentists practice. Our practice is a specialist practice and outcome centred. Research and experience suggests that treatment within a specialist practice will be much more likely to achieve a positive result and that this result is also likely to be longer lasting.
Periodontal maintenance and self care
The outcome of periodontal treatment is highly dependent on the levels of your home oral hygiene program and on long term professional periodontal maintenance. Natural teeth and their artificial replacements should be maintained daily in a clean, hygienic manner. You will need to brush your teeth as instructed and also be required to clean between your teeth (floss and inter dental brushes are most commonly used) daily.
You could elect not to seek treatment for your periodontal problems. This may result in ongoing bad breath, bleeding of the gums, loosening of teeth and potential loss of teeth due to periodontal disease in the future. It is essential to your long term stability that recommended periods for maintenance are undertaken.
Periodontal maintenance involves examination and assessment of the teeth and periodontal tissues, reinstruction in oral hygiene techniques and removal of plaque and calculus from teeth. Maintenance also may include adjustment of prosthetic appliances. Further treatment (in addition to ongoing periodontal maintenance) may be recommended at these visits if required. Periodontal maintenance may be carried out by a Periodontist, a Hygienist, a Dentist or a combination of these.
It is also important to continue to see a Dentist. Existing restorative dentistry can be an important factor in the success of failure of periodontal therapy. From time to time, the Periodontist may make recommendations for the placement of restorations, the replacement or modification of existing restorations, the joining together of two or more of my teeth, the extraction of one or more teeth, the performance of root canal therapy, or the movement of one, several, or all of my teeth. Failure to follow such recommendations could lead to ill effects, which would become the patient’s sole responsibility.
No Warranty or Guarantee
We give no guarantee, warranty or assurance that the proposed treatment will be successful. In most cases, the treatment should provide benefit in reducing the cause of periodontal disease and should produce healing which will help the patient keep teeth. Due to individual patient differences, however, a Periodontist cannot predict certainty of success. There is a risk of failure, relapse, additional treatment, or even worsening of the present condition, including the possible loss of certain teeth, despite the best of care.
I have been fully informed of the nature of periodontal therapy, the procedure/procedures to be utilized, the risks and benefits of periodontal therapy, the alternative treatments available, and the necessity for followup and self-care. I have had an opportunity to ask any questions I may have in connection with the treatment.
After thorough deliberation, I hereby consent to the performance of periodontal therapy as presented to me during consultation and in the treatment plan presentation as described in this document. I also to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my Periodontist.
I certify that I have read and fully understand this document.
You have been informed that you require, or would benefit from, veneers on the following teeth:
UPPER RIGHT 8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8 UPPER LEFTLOWER RIGHT 8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8 LOWER LEFT
PURPOSE OF THE TREATMENT:
This procedure is deemed necessary because the teeth are:
□ Heavily Restored
□ Poorly Spaced or Misaligned
□ Worn Down
□ For Aesthetic Purposes
A PORCELAIN VENEER PROCEDURE REQUIRES TWO TO THREE (2-3) APPOINTMENTS:
The first appointment will require 30-45 minutes of your time per veneer.
It consists of:
Anesthesia Tooth Reduction/Preparation
Tooth Isolation Impression(s) Taken
Shade Selection for Veneers
Fabrication of Temporary Veneers (if needed)
The second appointment will require 45-60 minutes of your time per veneer, approximately one week after the first appointment.
Removal of Temporary Veneers (if placed) Try-in of veneers
Preparation of veneers Preparation of Teeth Bonding of Veneers Bite Adjustment
Final Contouring and Polishing
If a third appointment is needed it will require 30-45 minutes of your time per veneer, approximately 3-5 days after the first appointment.
A RESIN VENEER PROCEDURE REQUIRES ONE (1) APPOINTMENTS
BENEFITS OF THE TREATMENT:The appearance of a previously unattractive tooth is corrected. Restorations replace diseased, missing, or defective tooth structure, and support or strengthen that which is remaining. They can improve chewing, allow proper speech, assist in the maintenance of healthy supporting tissue, and enhance appearance.
RISKS OF THE TREATMENT:Veneer preparation involves cutting away diseased and/or healthy tooth structure. In rare cases, removal of tooth structure may irritate the pulp of individual teeth. The appropriate treatment at this point is a root canal treatment. Although infrequent, this treatment may be required before, during or after the veneer procedure to alleviate discomfort or infection.
When impressions of a patient's mouth are being taken for dental lab specifications, the gum tissues which cover the edges of the tooth may have to be pushed back or trimmed away. Receding gums, a common aging process, may on occasion be accelerated by these steps. If gum recession occurs, the veneer margins may become visible, or the roots may be exposed. These areas require the application of desensitizing agents.
Sometimes it is necessary to adjust the shape of teeth other than those being restored. Joints, muscles, and ligaments of the jaws on occasion react adversely to even minor changes to the biting surfaces of the teeth. Minor reshaping may be required to ensure that any discomfort or pain is avoided.
A veneer may become loose or require replacement if decay has developed at the margins, or if heavy biting forces (grinding, clenching, biting habits) break down the bonding materials. Patients must be diligent with home oral hygiene in addition to being careful with biting and chewing.
Gums or tissues involved in the anesthetic injection may be sore for several days following treatment. Swelling of the tissues around the injection site is possible and can be treated by applying pressure and cold (i.e., ice packs) the day of treatment to the area of swelling for a minimum of 1-2 minutes. In addition, if freezing involves the lower jaws, there may be difficulty opening the jaw for the first few days. The soreness and stiffness will dissipate with time but warm saltwater rinses or moist heat on the side of treatment will facilitate healing. Transient facial paralysis is a rare possibility upon anesthetic injection, but it will almost always resolve itself without any future consequences.
ALTERNATIVES TO THE TREATMENT:Veneers are an option if less intrusive treatments ex. bleaching is not sufficient to adequately correct the problem. Crowning (capping) the tooth is also an alternative to treatment however, there are no alternatives that are less intrusive than veneers that yield the same quality results.
Regenerative dentistry is scientifically proven to enhance your body's own healing. It decreases your chances of having post-operative complications and helps attain better healing and better results for dental surgery by utilizing growth factors and other components of your own blood.
This procedure is widely used in medicine for such things as heart surgery, orthopedics, oral and maxillofacial surgery, plastic surgery, and dermatology. However, in dentistry we are now using the same procedure when a patient has a tooth extracted, wisdom teeth extracted, implants placed, or bone and gum grafting performed.
Platelet Rich Plasma (PRP) is a liquid form, and Platelet Rich Fibrin (PRF) is a gelled membrane form of the products that we make from a small quantity of blood that we take from the patient before their dental procedure begins. This blood is drawn in test tubes and spun in a centrifuge which separates the blood into it's individual components: 1) plasma, 2) red blood cells and 3) a small but very concentrated quantity of white blood cells and platelets which contains the healing and growth factors that we use to enhance healing.
The products that we separate out are immediately placed into the surgical site by themselves, mixed with bone grafting materials, or used as barrier membranes. This allows for better and faster soft tissue (gum) and hard tissue (bone) healing and regeneration. Because the healing is faster than usual, there is less chance of infection, dry socket, failed bone grafting, and failed implants. These procedures are especially helpful to those who otherwise might have impaired healing such as diabetics, smokers, and others with chronic or acute conditions which can interfere with healing.
BrightSmile Avenue Dental Clinic has recommended the use of Platelet Rich Plasma (PRP) and Platelet Rich Fibrin (PRF) to enhance post-operative healing. I understand I will have several vials of my own blood drawn and only my own blood is used for this procedure. My blood will be placed in a centrifuge to concentrate and activate the platelets. All blood drawing materials and containers are single use and are disposed in our medical waste containers after each patient, and all materials are sterile. I have had the opportunity to ask questions before signing this consent, and understand I can ask further questions at any time as well.
The nature and purpose of root canal treatment has been explained to me, and I have had an opportunity to have my questions answered. I understand that dentistry is not an exact science and success with root canals cannot be guaranteed. In view of the above information, I authorize the doctor and/or such associates and assistants as necessary to render any treatment necessary and/or advisable to my dental condition including any and all anesthetics and/or medications.
Because your child is a minor, it is necessary that signed permission be obtained from a parent or guardian before any/or all necessary dental treatment is performed. Diagnosis of services needed and financial obligations will be discussed with you by the doctor and/or staff before treatment is rendered.
Your signature authorized BrightSmile Avenue and/or its Pediatric Dentist Associate to render necessary dental treatment, to administer anesthetics, to administer medication, to take radiographs (X-rays), clinical photographs, study models and other records necessary for an accurate diagnosis, to utilize behavior management therapy as needed to provide safe dental care for your child and employ such assistance as is appropriate.
Providing quality dental care for children requires expertise in directing child behavior. Our goal is to instill in the child, a positive attitude towards dentistry. Maintaining proper behavior of children while in the dental office demands skill of verbal guidance, prevention of inappropriate actions, and reinforcement of appropriate behavior. These techniques are used only for behavioral modification and not to reprimand or punish a child.
The following are various behavior management techniques used in this office.
It is our office policy to minimize the use of more extreme forms of behavior management techniques and to implement them only when necessary.
By signing this form, I hereby acknowledge that I have read and understood and accept the provisions identified above.