1. I hereby authorize and direct Main Line Dental Health & Wellness, Dr. Jerald S. Matt, Dr. Naila Bryan, and dental auxiliaries of their choice, to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays), or diagnostic aids.
- Preventative hygiene treatment, (prophylaxis) and the application of topical fluoride.
- Application of plastic “sealants” to the grooves of the teeth.
- Treatment of diseased or injured teeth with dental restorations (fillings and crowns, etc.)
- Replacement of missing teeth with dental prosthesis, (bridges, partial dentures, full dentures, implants, etc.)
- Removal (extraction) of one or more teeth.
- Treatment of diseased or injured oral tissues (hard and/or soft).
- Use of sedative drugs to control apprehension and/or disruptive behavior.
- Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.
- Use of local anesthesia to accomplish the necessary treatment.
2. I understand that there is risks involved in this treatment and hereby acknowledge that these risks will be explained to me, and that I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.
3. I will be advised that the success of the dental treatment to be provided will require that the patient and/or parents of the patient following post-operative and post-care instructions of the dentist/s. I agree that the success of treatment requires that all postoperative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his/her auxiliaries must be maintained.
4. I recognized that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from the discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and well being, in the professional judgment of the dentist.
5. There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common are swelling, bleeding, pain , nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face and tongue, allergic reactions, hematoma, (swelling or bleeding at or near the injection site), fainting, lip or cheek biting resulting in ulceration and infection of mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.
6. I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor/s. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nosepiece leaves an indentation or ring around the nose, which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.
7. I also authorize Main Line Dental Health & Wellness to take and use photographs, radiographs, videos and/or other diagnostic materials before, during and after treatment. I consent to allow photographs, radiographs, videos and/or other diagnostic materials to be used for the following purposes: treatment/dental records, education; including lectures, seminars, patient education, demonstrations, professional publications such as journals or books, research, marketing material; including websites and printed materials. I do not expect compensation, financial or otherwise for the use of these photographic/radiographic/video materials.
8. I hereby state that I have read and understand this content, and that all questions about the procedure will be answered in a satisfactory manner; and I understand that I have the right to be provided answers to the questions which may arise during and after the course of my treatment.
9. I further understand that this content will remain in effect until such time as I choose to terminate it.