First Name Last Name understand and consent to the following regarding the dental veneer procedure: 1. Purpose: Dental veneers are being placed to improve the appearance of my teeth by covering imperfections such as chips, stains, or gaps. 2. Procedure Description: The dentist will prepare the teeth by removing a small amount of enamel to create space for the veneers. Impressions of the teeth will be taken and sent to a dental laboratory for the fabrication of the veneers. Temporary veneers may be placed while waiting for the final veneers. Once the veneers are ready, they will be bonded to the teeth using dental cement. 3. Risks and Limitations: I understand that, like any dental procedure, there are risks involved. These may include tooth sensitivity, gum irritation, and the possibility of the veneers becoming loose or dislodged. I also understand that the color of the veneers cannot be changed once they are placed, and that they may need to be replaced or repaired in the future. 4. Alternatives: I have been informed of alternative treatments to dental veneers, such as teeth whitening, orthodontic treatment, or dental bonding. I understand that I have the right to choose an alternative treatment option if desired. 5. Cost and Insurance: I understand that veneers are not typically covered by insurance, and I am responsible for the full cost of the procedure. I have been provided with an estimate of the cost and have had the opportunity to ask any questions regarding payment. 6. Aftercare: I understand that proper oral hygiene, including regular brushing, flossing, and dental check-ups, is necessary to maintain the longevity of the veneers. I will follow the dentist’s instructions for care and maintenance of the veneers.I have had the opportunity to ask questions and have received satisfactory answers. I consent to the dental veneer procedure and understand the risks, benefits, and alternatives involved. Signature