General Dental Treatment Consent Form
Please read, initial the items checked below, and sign the bottom of the form.
______EXAMINATION, PREVENTATIVE CARE, TREATMENT, AND X-RAYS
I understand that during my course of treatment, the following care may be provided: examinations, preventative services, diagnosis, basic restorative, and crowns. I understand that during my initial visit and periodically thereafter, or as needed, I may require radiographs to complete the examination, diagnosis, and treatment plan.
______DRUGS AND MEDICATIONS
I understand that I may receive a local anesthetic and/or other medication. In rare instances, patients may have a severe reaction to the anesthetic, which may require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the chance of swallowing or aspirating foreign objects during treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury can result from an injection.
______BASIC FILLINGS AND RESTORATIONS
I understand that I may experience hot and cold sensitivity, pain, or discomfort following routine restorative procedures and that this is usually temporary and should settle without further treatment. If my condition does not get any better, I understand that I may need further dental treatment, the most common being root canal therapy, resulting in additional costs. I understand that care must be exercised in chewing on the new filling during the first 24 hours to avoid breakage.
______CROWNS, BRIDGES, VENEERS, AND BONDING
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. I realized that the final opportunity to make changes in my new crowns, bridge, or veneer (including shape, fit, size, placement, and color) would be done before cementation. I understand that in very few cases, cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures.
______GENERAL RISKS OF DENTAL PROCEDURES
General risks include (but are not limited to) complications resulting from the use of dental instruments, drugs, medicines, analgesics (pain killers), anesthetics, and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness, and tingling sensations in the lip, tongue, chin, gums, cheeks, and teeth; thrombophlebitis (inflammation to a vein), change in occlusion (biting), muscle cramps, and spasms; temporomandibular jaw (TMJ) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues; and referred pain to the ear, neck, and head, nausea, allergic reactions, itching, bruises, delayed healing, sinus complications, and further surgery.
______ALTERNATIVES
I understand that I have the right to choose, based on adequate information, from alternate treatment plans that meet professional standards of care. I have no further questions.
