Dentist_______________ Patient__________________ Date________________
1. LOCAL ANESTHESIA AND NITROUS OXIDE
I understand that analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain itching, vomiting, anaphylactic shock and nausea. (Initials __________) For Females, I am not pregnant and I understand that nitrous oxide has been shown to cause complications if Pregnant.
2. CROWNS, BRIDGES, INLAYS/ ONLAYS & FILLINGS
I understand that I have old restorations/fillings that Dr. Patel is going to replace and/or I understand that I have tooth decay present. If the old filling/ tooth decay/ cavity appears to be very deep into the tooth, there may be a possibility in needing a Root Canal. Underneath old fillings there is no telling how much tooth decay is exactly present until the procedure is performed. As Dr. Patel removes the tooth decay, if the decay has penetrated into the nerve and the nerve becomes bruised, exposed, or traumatized there is a very high chance that a Root Canal will need to be done to make the tooth healthier. If there is a minor exposure of the nerve, Dr. Patel may place a medicine over the exposure in hopes for healing. If the tooth is at all symptomatic, sensitive, and/or painful I understand that I will need a Root Canal because of the deep tooth decay that was present. (Initials__________)
3. REMOVAL OF TEETH
I agree to the following procedure _______________ due to the condition _______________. Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.), and I authorize the Dentist to remove the following teeth. I understand that removing teeth does not always remove all the infection, if present, 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 socket, loss of feeling in my teeth, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time of fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility. (Initials__________)
4. IMPLANT SURGERY
All of my treatment options have been explained to me. I authorize Dr. Patel to place implant(s) to replace the missing teeth #_______. I understand the risks involved in having implant surgery and their complications, some of which are pain, swelling, spread of infection, bleeding, loss of feeling in my teeth, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time, damage to sinus cavity or nerves, damage to bone, or fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility and not included in the current treatment. (Initials _____________)
I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate denture (placement of dentures immediately after extractions) may be painful. Immediate denture may require considerable adjusting and several relines. A permanent reline will be necessary later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep delivery appointment may result in poorly fitted dentures. If a remake is required die to my delays of more than 30 days, there will be additional charges. (Initials__________)
6. ENDODONTIC TREATMENT (ROOT CANAL)
I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally the canal filling material may extend through the tooth which does not necessarily effect the success of the treatment. I understand that endodontics files and reamers are very fine instruments and stresses vented in their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts to save it. (Initials__________)
I understand that if I present with a restoration that has come loose or fallen off that the restoration may need to be completely redone. If the restoration appears to clinically fit and is acceptable, it may be re-cemented. After re-cementation there is no guarantee upon how the restoration will look afterwards, fit, and how long it will ultimately last. Again, the restoration may have to be redone at a designated fee to achieve the best results. (Initials________)
I understand the information stated above & I consent to the recommended treatment.