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Informed Consent Form

Comprehensive Exam, X-rays, prophylaxis

Drugs, medications and injection of anesthetics

I understand that antibiotics, analgesics, anti-inflammatories, anesthetics, other medications or instruments used to administrate them, for example an injection, can cause adverse or allergic reactions causing discoloration, redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction) temporary or permanent numbness or tingling of the tongue and the jaw (hard or soft tissue), or other medical emergencies for which I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

Changes in treatment plan

The patient understands that dentistry is not an exact science and that the treatment plan that they had agreed to may need to be changed if an unforeseen event occurs, other or new conditions are found, or necessary work is required that was not part of the original diagnosis and treatment plan. The most common, being root canal therapy following routine restorative procedures. Under the circumstances the cost of treatment may go up or down. I give my permission to the dentist to make any/all changes and additions as necessary.

White fillings - restorative dentistry

Alternatives to white (composite) fillings have been explained to me (silver amalgam fillings, crowns, etc.) I have requested white (composite) fillings. I understand that this filling material is not as strong as silver and will not last as long. On occasion, it does not insulate as well and the tooth might be more sensitive, and may have to be replaced with a filling or otherwise at my expense.

Removal of teeth - oral surgery

Alternatives to teeth removal have been explained to me (root canal therapy, etc.) I authorize the dentist to remove the teeth that we agreed upon and any other ones to perform oral surgical procedures found necessary by the dentist to complete the procedure or improve the results. Removing the teeth does not always remove all the infection, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry sockets, loss of feeling or tingling in my teeth, lips, tongue, and surrounding tissues (paresthesia) that can be temporary or permanent, fractured jaw, TMJ dysfunction which causes pain and clicking in the jaw joints, and may require surgery or physical therapy to treat, causing an opening into the sinus. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

Crowns, bridges and veneers

I understand that sometimes 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 and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. Temporary crowns are not a substitute to permanent crowns, and as such cannot be worn for prolonged time periods, to avoid damage to oral structures. I realize the final opportunity to make changes to my new crown, bridge, veneer (including shape, fit, bite, size and color) will be before cementation or after the tooth is prepared for crown, bridge, or veneer, the cost of which is not included in the fee for the crown veneer or bridge.

Dentures - complete or partial

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me including looseness, soreness, and possible leakage. I realize the FINAL opportunity to make changes in my new denture (including shape, fit, bite, size, placement and color) will be in the “teeth in wax” try-in visit. Changes thereafter can be made only at additional cost to the patient. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost of those procedures is not included in the initial denture fee.

Endodontic treatment (root canal)

I realize that there is no guarantee that root canal treatment will save my tooth, and complications can occur from the treatment, including pain, swelling, reinfection and sensitivity to pressure before and after the root canal is sealed, and occasionally objects are cemented in the tooth or extend through the root which does not necessarily effect the success of the treatment. Treatment could be discontinued due to calcified, inaccessible canals, perforations, resorption, accidental broken files, or fracture of root or crown, and I may be referred to a specialist to complete or modify the procedure, at additional cost, if the dentist finds it necessary. We recommend placement of a crown and post buildup to protect and to avoid further decay and fracture of root canal treated teeth. Teeth that are left unprotected and decayed or fractured will become unrestorable, and will be extracted. I understand that occasionally an additional surgical procedure may be necessary following root canal treatment (apicoectomy). Keeping my mouth wide open during the root canal procedure, which usually is a long procedure may cause or worse TMJ dysfunction, which causes pain and clicking in the jaw joints, it also causes restricted opening and may need physical therapy or surgery to treat at an additional charge to the patient.

Periodontal Therapy: surgical or non-surgical gum treatment

I understand that periodontal disease destroys the gum and bone, causing tooth loss. Either the surgical or non-surgical treatment may cause prolonged bleeding, short or long-term sensitivity to hot or cold food and drinks, chemicals, touch or air. Pastes or gels usually reduce the sensitivity, and permanent sensitivity is very rare. As with other dental procedures there could be pain, swelling or infection after the dental procedure. The success of the procedure is not guaranteed, and one or more teeth may need root amputation, root canal therapy, or extraction after the periodontal procedure, at an additional cost to the patient. After the procedure, there could be some recession of the gum causing the teeth to appear longer, providing spaces between the teeth where food and other debris could accumulate. Frequent, timely evaluations and maintenance visits will be necessary. Periodontal disease is a chronic disease. We recommend periodontal follow up or recall-cleanings every 3 to 6 months. Many dental appliances and procedures, including fillings, crown, bridges, and partials, can have an adverse effect on the periodontal condition and must also be periodically evaluated. Very frequently, non-surgical treatment is followed by surgical treatment, the cost of which is not included with the initial non-surgical treatment. You could reduce your chances of needing surgery, by closely following your dentists instructions and recommended follow-up care. I understand that dentistry is not an exact science and that, therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized. I understand and agree that each dentist is an individual practitioner and individually and solely responsible for the dental care rendered to me.

Notice of privacy practices (hipaa)

This notice is effective and we are required to abide by the terms of the notice of privacy practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our notice of privacy practices will be posted on the effective date and you may request a written copy of the revised notice from this office. I have read the notice of privacy act this is posted in this office, and I agree to ask for a copy if I want one.

The nature of the specific dental procedures has been described to me and explained in the above paragraphs. I understand and agree that the dentist that treats me is the only one responsible for my care. I have read and understood the above, including risks and limitations of each procedure, and the possibility that treatment may not be 100% successful. On this basis, I consent to every separate step of the treatment, and I also am acknowledging that I have read and understood the notice of privacy act (HIPAA) form that is posted in this office.


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