I UNDERSTAND that dental treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and/or failure associated with, but not limited to the following:

1. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment can cause teeth to become sensitive. Studies have shown that 4-8% of crowned teeth will require root canal treatment within 10 years. Should sensitivity occur and persist for any length of time, please contact this office for an examination.
2. Chipping, breaking, or loosening: Careful and diligent treatment planning is important to minimize the risk of having any breakage. Many factors may also contribute to damage - chewing of hard materials; grinding or clenching; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which the doctor has no control. Following the post-op instruction given at your final appointment will increase the longevity of your prosthetic.
3. Esthetics and appearance: Every effort possible will be made to match and coordinate both the form, function and shade of prosthetic. However, there are some differences which may exist between the natural dentition and the materials which are artificial. The dentist will discuss any limitations that may prevent your final prosthetic from perfectly matching your natural dentition.
4. Longevity: it is impossible to accurately estimate the lifetime of your prosthetic. The longevity may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient's individual habits or circumstances, which may be either internal, external or both.
5. It is the patient's responsibility to immediately inform the doctor and seek attention from him/her should any problems occur, or if the patient is dissatisfied. Also, all postoperative instructions must be diligently followed, including correctly wearing any appliances given to protect your prosthetic, maintaining good oral hygiene and home care, as well as attending regular hygiene and dental appointments.

INFORMED CONSENT: I have been given the opportunity to ask any and all questions regarding the nature and purpose of treatment and have received all answers to my satisfaction. I voluntarily assume any and all possible risks, including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results. The fee(s) for these services have been explained to me and are satisfactory.

By signing this form, I am giving my consent to allow and authorize my dentist to render any treatment deemed necessary, desirable, and/or advisable to me, including the administration and/or prescribing of any anesthetics and/or medications.