INFORMED CONSENT
TREATMENT TO BE DONE: I understand and consent to have any treatment done by the
dentist after the procedure, the risks & benefits & cost have been fully explained. These
treatments include, but are not limited to cleanings, periodontal treatments, filling, crowns,
bridges, all types of extraction, root canals. &/or dentures local anesthetics & surgical cases.
(Initial: __________)
DRUGS & MEDICATIONS: I understand that antibiotics, analgesics & other medications can
cause allergic reactions like redness & swelling of tissues, pain, itching, vomiting, &/or
anaphylactic shock. (Initial: __________)
CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to
change/add procedures because of conditions found while working on the teeth was not
discovered during examination for example, root canal therapy may be needed following
restorative procedures. I give my permission to the dentist is make any/all changes and
additions as necessary w/ my responsibility to pay all the costs agreed.
(Initial: __________)
RADIOGRAPH: I understand that an x-ray shot or a radiograph maybe necessary as part of
diagnostic aid to come up with tentative diagnosis of my Dental problem and to make a good
treatment plan, but, this will not give 100% assurance for the accuracy of the since all dental
treatments are subject to unpredictable complications that later on may lead to sudden
change of treatment plan and subject to new charges. (Initial: __________)
REMOVAL OF TEETH: I understand that alternatives to tooth removal (root canal therapy,
crowns & periodontal surgery, etc.) & I completely understand the alternatives, including their
risk & benefits prior to authorizing the dentist to remove teeth & any other structures
necessary for reasons above. I understand that removing teeth does not always remove all
the infections, it present, & it may be necessary to have further treatment. I understand the
risk involved in having teeth removed, such as pain, swelling, spread of infection, dry socket
fractured jaw, loss of feeling on the teeth, lips, tongue & surrounding tissue that can last for an
indefinite period of time. I understand that may need further treatment under specialist
complications arise during or following treatment. (Initial: __________)
CROWNS (CAPS) & BRIDGES: Preparing a tooth may irritate the nerves tissue in the center
of the tooth, leaving the tooth extra sensitive to heat, cold and pressure. Treating such
irritation may involve using special toothpastes, mouth rinses or root canal therapy. I
understand that something it is not possible to match the color of natural teeth exactly with
artificial teeth. I further understand that I may be wearing temporary crowns
, which may come off easily & that I must be careful to ensure that they are kept on until the
permanent crowns are delivered. It is my responsibility to return for permanent cementation
within 20 days form tooth preparation, as excessive days delay may allow for tooth movement.
Which may necessitate a remake of the crown, bridge/ cap. I understand there will be
additional charges for remakes due to my delaying of permanent cementation. & I realize that
final opportunity to make changes in my new crown, bridges or cap (including shape, fit, size,
& color) will be before permanent cementation. (Initial: __________)
ENDODONTICS (ROOT CANAL) : understand there is no guarantee that a root canal
treatment will save a tooth & that complications can occur from
the treatment & that occasionally root canal filling materials may extend through the tooth
which does not necessarily effect the success of the treatment.
I understand that endodontic files & drills are very fine instruments & stresses vented in their
manufacture & calcifications present in teeth can cause them to break during use. I
understand that referral to the endodontist for additional treatments may be necessary
following any root canal treatment & I agree that I am responsible for any additional cost for
treatment performed by the endodontist. I understand that a tooth may require removal in
spite of all efforts. (Initial: __________)
PERIODONTAL DISEASE: I understand that periodontal disease is a serious condition
causing gum & bone inflammation & for loss & that can lead eventually to the loss of my teeth.
I understand the alternative treatment plans to correct periodontal disease, including gum
surgery tooth extractions with or without replacement, I understand that undertaking any
dental procedures may have future adverse effect on my periodontal.
FILLINGS: understand that care must be exercised in chewing on fillings, especially during
the first 24 hours to avoid breakage. I understand that a more
extensive filling or a crown may be required, as additional decay or fracture may become
evident after initial excavation. I understand that significant sensitivity is a common, but
usually temporary, after-effect of a newly placed filling. I further understand that filling tooth
may irritate the nerve tissue creating sensitivity & treating such sensitivity could require root
canal therapy or extractions. (Initial: __________)
DENTURES: I understand that wearing of dentures can be difficult. Sore spots, altered
speech & difficulty in eating are common problems. Immediate dentures (placement of
denture immediately after extractions) may be painful. Immediate dentures may require
considerable adjusting & several refines. I understand that it is my responsibility to return for
delivery of dentures. I understand that failure to keep my delivery appointment may result in
poorly fitted dentures. If a remake is required due to my delays of more than 30 days, there
will be additional charges. A permanent reline will be needed later, which is not included in the
initial fee. I understand that all adjustment or alterations of any kind after the initial period is
subject to charge. (Initial: __________)
I understand that dentistry is not an exact science and that no dentist can
property guarantee accurate results all the time.
I hereby authorize any of the doctors/dental auxiliaries to proceed with perform the dental
restorations & treatments an explained to me. I understand that these are subject to
modification depending on undiagnosable circumstances that may arise during the course of
treatment. I understand that regardless of any dental insurance coverage I may have, I am
responsible for payment of dental fees. I agree to pay any attorney's fees, collection fee, or
court costs that may be incurred to satisfy any obligation to this office. All treatment were
properly explained to me & my untoward circumstances that may arise during the procedure,
the attending dentist will not be held liable since it is my free will, with full trust & confidence in
him/her, to undergo dental treatment under his/her care
Patient/Parent/Guardian Signature
___________________________
Dentist Signature
___________________________
Dale
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