The prognosis, or likelihood of success, of this treatment is   Type a label        
My crown restoration(s) is/are estimated to cost $ Type a labeland is estimated to take Type a labelvisit(s) to complete.

Depending on my diagnosis, there may or may not be alternatives to a crown restoration that involve other types of dental care. I understand that possible alternatives to crown restorations may be:

• Other restorative alternatives, such as onlay, inlay, veneer, or a filling. Fillings may be made of dental amalgam (silver color) or a tooth-colored filling material
• Extraction. I may decide to have tooth #      removed. The extracted tooth usually requires replacement by an artificial tooth by means of a fixed bridge, dental implant with a crown, or a removable partial denture. 
• No treatment. I may decide to have no treatment performed at all. If I decide upon no treatment, my condition may worsen and I may risk serious personal injury, including severe pain; localized infection; loss of this tooth and possibly other teeth; severe swelling; and/or a severe (spreading) infection.

Patient’s Initials    I have had an opportunity to ask questions about these alternatives and any other treatments I have heard or thought about, including       

I have been informed and fully understand that there are certain inherent and potential risks associated with crown restorations. I understand that the nerve inside my tooth may be irritated by treatment and I may experience pain or discomfort during and/or after treatment. My tooth may become more sensitive to hot and cold liquids and foods. I understand that root canal treatment may become necessary at any time during or after treatment and may not be avoidable. I understand that a crown restoration may not relieve my symptoms.

I understand that once prior fillings and decay are removed, it may reveal a more severe condition of my tooth. This condition may require periodontal (gum) surgery to uncover more of the tooth, may require root canal treatment in addition to a crown restoration, or may instead require the extraction of the tooth.

I understand that I may notice slight changes in my bite. I understand that during and for several days following treatment, I may experience stiff and sore jaws from keeping my mouth open.

I understand there may be injury to my gums around the tooth. I understand that my gums may recede after the completion of my crown restoration. I understand that poor eating habits, oral habits (smoking, fingernail biting, etc.), and poor oral hygiene will negatively affect how long my crown lasts.

I understand that I may be given a topical anesthetic and/or local anesthetic injection. Although rare, it is possible that patients may have an allergic reaction to these medications. Adverse reactions to anesthetic medications are possible, such as lightheaded- ness, dizziness or drowsiness. Please contact Dr.  Dr. Nameif numbness remains more than a few hours or if you develop a rash. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from the anesthetic injection. I also understand that temporary or permanent injury to nerves and/or blood vessels from the injection may occur. Nerve disturbances may include pain or numbness, and/or unusual sensations such as itching, burning, or tingling of the lip, tongue, chin, teeth, and/or mouth tissues. I understand that once a crown restoration is started, I must promptly return to have the crown finished. If I fail to return to have the crown completed, I risk decay, the need for root canal treatment, tooth fracture and loss of the tooth.

Other foreseeable risks not stated above include:       

Patient’s Initials I have had an opportunity to ask questions about these risks and any other risks I have heard or thought about, including       

I have provided as accurate and complete a medical and personal history as possible, including medications I am currently taking (antibiotics, pain drugs, or other medications, including non-prescription medicines, herbs or supplements) and materials or medicines to which I am allergic. I will follow any and all treatment and post-treatment instructions as directed and explained to me and will permit the recommended diagnostic procedures, including X-rays.

I realize that in spite of the possible complications and risks, my recommended crown restoration is necessary. I am aware that the practice of dentistry is not an exact science and I acknowledge that no guarantees, warranties, or representations have been made to me concerning the results of the treatment

I,    Name   , have received information about the proposed treatment. I have discussed my treatment with Dr.   Dr. Name   and have been given an opportunity to ask questions and have them fully answered. I understand the nature of the recommended treatment, alternate treatment options, the risks of the recommended treatment, and the risks of refusing treatment.

I wish to proceed with the recommended treatment.

Patient’s Initials     I understand this treatment can also be performed by a prosthodontist (a crown specialist). I understand the risks associated with this treatment and elect to have this procedure performed by Dr.    Dr. Name 
I understand that if any unexpected difficulties occur during treatment, I may be referred to a prosthodontist for further restorative care of this tooth.