consent to the use and disclosure of my personal health information by your office for Treatment,
and Healthcare Operations as outlined in the NOTICE OF PRIVACY PRACTICES.
Informed Consent General Dentistry
All patients complete 1 thru 4 below, and 5 thru 13 as
EXAMINATIONS AND X-RAYS I understand that the initial visit may require
in order to complete the examination, diagnosis, and treatment plan. I understand I am to have work
detailed in the attached treatment plan.
DRUGS, MEDICATION, AND SEDATION I have been informed and understand that
analgesics and other medications can cause allergic reactions causing redness and swelling of
itching, vomiting, and/or anaphylactic shock (severe allergic reactions). I have informed the
allergies. They may cause drowsiness, lack of awareness, and coordination which can be increased by
alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device
hours or until fully recovered from the effects of the anesthetic, medication, and drugs that may
in the office for my care. I understand that failure to take medications prescribed for me in the
may offer risks of continued or aggravated infection and pain and potential resistance to effective
treatment of my
condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth
I understand that all medications have the potential for accompanying risks, side effects, and drug
Therefore, it is critical that I tell my dentist of all medications I am currently taking.
CHANGES IN TREATMENT PLAN I understand that during treatment it may be
change or add procedures because of conditions found while working on the teeth that were not
examination, the most common being root canal therapy following routine restorative procedures. I
to the Dentist to make any/all changes and additions as necessary.
TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD) I understand that popping,
and pain can intensify or develop in the joints of the lower jaw (near the ear) subsequent to
treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with
are usually transitory in nature and well tolerated by most patients. I understand that should the
treatment arise, then I will be referred to a specialist for treatment, the cost of which is my
DENTAL PROPHYLAXIS (CLEANING) I understand the treatment is preventive
intended for patients with healthy gums, and is limited to the removal of plaque and calculus from
structures in the absence of periodontal (gum) disease.
FILLINGS I understand that a more extensive restoration than originally
diagnosed may be
required to additional decay or unsupported tooth structure found during preparation. This may lead
measures necessary to restore the tooth to normal function. This may include root canal, crown, or
understand that care must be exercised in chewing on fillings during the first 24 hours to avoid
understand that sensitivity is a common after-effect of a newly placed filling.
REMOVAL OF TEETH Alternatives to removal have been explained to me (root
crown, and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth.
and any others necessary for reasons in paragraph #3. I understand removing teeth does not always
infection, if present, and it may be necessary to have further treatment. I understand the risks
having teeth removed, some of which are pain, swelling, the spread of infection, dry socket,
loss of feeling in my teeth, lips, tongue, and surrounding tissue (Parasthesia) that can last
period of time or fractured jaw. I understand bleeding could last for several hours. Should it
particularly if it's severe in nature, it should receive attention and this office must be
understand that I may need further treatment by a specialist or even hospitalization if
during or following treatment, the cost of which is my responsibility.
CROWNS, BRIDGES, VENEERS, AND BONDING a. I understand that sometimes
to match the color of natural teeth exactly with artificial teeth. I further understand that I
temporary crowns, which may come off easily, and that I must be careful to ensure that they are
permanent crowns are delivered. I realize that the final opportunity to make changes in my new
veneer (including shape, fit, size, and color) will be before cementation. It has been explained
that in a
very few cases, cosmetic procedures may result in the need for future root canal treatment,
predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and
modification of daily cleaning procedures. It is also my responsibility to return for permanent
20 days after tooth preparation. Excessive delays may allow for decay, tooth movement, gum
problems. This may necessitate a remake of the crown, bridge, or veneer. I understand there will
charges for remakes or other treatment due to my delaying permanent cementation.
b. I am electing to use noble, high noble or ceramic instead of base metal in my crown and bridge
c. I am electing to do a fixed bridge or implant replacement of missing teeth instead of a
understand that this fixed bridge or implant and crown may not be a covered benefit under my
DENTURES - COMPLETE OR PARTIAL I realize that full or partial
constructed of plastic, metal, and/or porcelain. The problems of wearing those appliances have
explained to me
including looseness, soreness, and possible breakage. I realize the final opportunity to make
denture (including shape, fit, size, placement, and color) will be the "teeth in wax" try-in
dentures (placement of dentures immediately after extractions) may be uncomfortable at first.
require several adjustments and relines. A permanent reline or a second set of dentures will be
This is not included in the initial denture fee. I understand that most dentures require
three to twelve months after initial placement. The cost for this procedure is not included in
fee. I understand that it is my responsibility to return for delivery of dentures. I understand
failure to keep
delivery appointments may result in poorly fitted dentures. If a remake is required due to my
more than 30
days, there will be additional charges.
ENDODONTIC TREATMENT (ROOT CANAL) I realize there is no guarantee
treatment will save my tooth, that complications can occur from the treatment, and that
may extend through the root tip which does not necessarily affect the success of the treatment.
tooth may be
sensitive during treatment and even remain tender for a time after treatment. Hard to detect
fracture is one of
the main reasons root canal fail. Since teeth with root canals are more brittle than other
necessary to strengthen and preserve the tooth. I understand that endodontic files and reamers
instruments and stresses can cause them to separate during use. I understand that occasionally
procedures may be necessary following root canal treatment (Apicoectomy). I understand that the
may be lost in
spite of all efforts to save it.
PERIODONTAL TREATMENT I understand that I have a serious condition
inflammation and/or bone loss and that it can lead to the loss of my teeth and/or negative
(including uncontrolled diabetes, heart disease, and pre-term labor, etc). Alternative treatment
explained to me, including non-surgical therapy, antibiotic/antimicrobial treatment, gum
extractions. I understand the success of any treatment depends in part on my efforts to brush
receove regular therapeutic cleanings as directed, follow a healthy diet, avoid tobacco products
recommendations. I understand bleeding could last for several hours. Should it persist,
it is severe
in nature, it should receive attention and this office must be contacted. I understand that
have a future adverse effect on the long-term success of dental restoration work.
IMPLANTS I understand that no dentistry is permanent and that ideal
may not be possible based on anatomic limitations. I have been informed that there is always the
failure resulting from the tissues of the body not physiologically accepting these artificial
infections may occur postoperatively which may necessitate the removal of the affected
is the slight possibility of injury to the nerves of the face and tissues of the oral cavity,
be of a temporary or, rarely, permanent in nature. I understand that it is absolutely necessary
to have regular periodic examinations and cleanings. I agree to assume the responsibility to
report as instructed by the treating dentist.
BLEACHING Bleaching is a procedure done either in-office
hour) or with
take-home trays (several treatments over 2-4 weeks). The degree of whitening varies with the
patient achieves considerable change (1-3 shades on the dental shade guide). Coffee, tea, and
teeth after treatment and are to be avoided for at least 24 hours after treatment. I understand
sensitivity of the teeth and/or gum inflammation, which may subside when treatment is
prescribe fluoride treatments to aid with sensitivity. Carbamide peroxide and other peroxide
used in teeth
bleaching are approved by the FDA as mouth antiseptics. Their use as bleaching agents has
of treatment means acceptance of risk. Pregnant women are advised to consult with their
NITROUS OXIDE I elect to have nitrous oxide in conjunction with my
have been informed and understand the possible side effects that may occur. These include, but
nausea, vomiting, dizziness, and headache. I understand that nitrous oxide use is not indicated
DENTAL BENEFITS I understand that my insurance may provide only a
care. I understand that submitting insurance and receiving a benefit is my responsibility. I
Dentist's recommendation of optimal dental treatment.
I understand that dentistry is not an exact science and that therefore reputable
properly guarantee results. I acknowledge that no guarantee or assurance has been made by
dental treatment I have requested and authorized. I understand that each Dentist is an
and is individually responsible for the dental care rendered to me. I also understand that
corporate entity, other that the treating Dentist, is responsible for my dental treatment. I
receipt of and understand post-operative instructions and have been given an appointment