425 main street west seneca, new york 14224

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(716) 674-5256
Consent for Dental Treatment:
_______________________________ ___________________

Patient Name Date


____1. TREATMENT: I understand I may have the following dental treatment performed:

□ Fillings □ Crowns □ Bridges □ Dentures □ Extractions □ Impacted tooth removal □ Root Canal Therapy □ Other

____2. Drugs and Medications: I understand that antibiotic, analgesics, anesthetics and other

medications can cause allergic reactions, resulting in redness and swelling of tissues, pain, nausea, and vomiting or more severe allergic reactions. I have informed the doctor of any known allergies. Certain medications may cause drowsiness and it is advisable not to drive or operate hazardous equipment when using such drugs.

____3. Fillings: I understand that a more extensive restoration than originally planned may be

required due to additional conditions discovered during preparation. I understand that significant changes in response to temperature may occur after tooth restoration. I am aware that root canal therapy may also be required in order to save the tooth. I realize that fillings are rarely “permanent” and usually require periodic replacement.

____4. Crowns and Bridges: I understand that it is sometimes not possible to exactly match the

color of natural teeth with artificial teeth. I further understand that I may be wearing temporary crowns that are prone to loosening and may need re-cementing. I will notify my doctor of that occurrence so that a temporary restoration is maintained until the final restoration is delivered. I realize that any changes that I may desire in color, shape, size, and etc. of a crown must be made prior to final fabrication of the restoration. It is my responsibility to return within one month of tooth preparation for final cementation of the restoration. I understand I may need further treatment by a specialist if complications arise during treatment including Root Canal Therapy; any costs thus incurred are my responsibility.

____5. Dentures: I understand that wearing dentures is not a simple process, that chewing

efficiency will be diminished, and that dentures are not “permanent.” Sore spots, altered speech and difficulty eating are common problems. Immediate dentures (placement of a denture immediately after extractions) may be quite uncomfortable for several days. Immediate dentures require frequent adjustment and one or more permanent relines within several months. I understand that failure to keep appointments may result in a less desirable result. If remake is required due to my delay, additional fees may be incurred.

____6. Extractions: Alternatives to tooth removal include root canal therapy, extensive

restoration, periodontal (gum) treatment or crowns. I understand that removing teeth does not always remove existing infection and that further treatment may be necessary. I have been told that the risks of removing teeth include, but are not limited to pain, swelling, infection, dry socket, fracture of bone or jaw, and loss of feeling in my lip and or other facial areas, cheek, tongue, gums and teeth. Such numbness may be temporary or permanent. I understand that further care by a specialist may be needed if complications arise during or after treatment, and that the cost incurred are my responsibility.

____7. Periodontal Disease: Periodontal disease can be a serious condition, causing gum and

bone inflammation and/or loss, and may lead to loss of permanent teeth. Possible treatment plans have been explained to me, including deep cleaning, gum surgery and bone grafting, extraction of teeth and tooth replacement. I do understand that much of the success of periodontal treatment depends on my continuing home care and faithful adherence to following my doctor’s instruction, including strict observance of recall appointments. I understand that care by a specialist may be necessary.

____8. Root Canal Therapy: I realize that there is no guarantee that root canal treatment will

save a tooth, and that complications can occur from treatment. Occasionally the canal filling material may extend through the end of the root, which may or may not affect the success of treatment, and which may require additional treatment. I understand that the root canal files are extremely fragile instruments and may sometimes separate within the root, which may or may not affect success; I understand that additional surgical procedures (apicoectomy) may be necessary to complete therapy. I also understand that an undetectable hairline crack in a tooth may cause failure, no matter how extensive therapy may be. A small percentage of root canals fail despite the best efforts. I understand that specialty care may be indicated if complications arise. I understand that I have the choice in seeking a specialist for this type of treatment and that specialty care may be indicated if complications arise.

____9. Changes in Treatment Plan: I understand that during treatment it may be necessary to

change or add procedures because of conditions discovered during treatment that were not evident during examination. I authorize my doctor to use professional judgment to provide appropriate care.

____10. Alternative Treatment(s):

I understand that dentistry is not an exact science and that no specific results can be assured or guaranteed. I acknowledge that no such guarantees have been made regarding the dental treatment I have authorized. I understand that the treatment plan and fees proposed are subject to modification, depending upon unforeseen or undiagnosed conditions that may be recognized only during the course of treatment. I understand that any associated laboratory fees are my financial responsibility.

CONSENT: I have had the opportunity to have all of my questions answered by my doctor and I certify that I understand English. My signature below signifies that I understand the treatment and anesthesia that is proposed for me, together with the known risks and complications associated with that treatment. I hereby give my consent for the treatment I have chosen.
___________________________________ __________________________

Patient’s (or Legal Guardian’s) Signature Date

___________________________________ __________________________

Doctor’s Signature Date

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Witness’s Signature Date

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