General consent form

Download 32 Kb.
Size32 Kb.

TREATMENT PLAN: I consent to have the complete examination with the necessary dental x-rays and cleaning in order to provide a realistic and comprehensive treatment plan. This treatment plan is not finalized until the proposed services are completed.
DRUGS, MEDICATIONS, AND ANESTHESIA: I understand that antibiotics, analgesics, and other medications may cause adverse reactions, some of which are, but are not limited to, redness and swelling of tissues, pain, itching, anaphylactic shock (severe allergic reaction) vomiting, dizziness, miscarriage, cardiac arrest. I have informed the Dentist of any known allergies. I understand that medications, drugs, and anesthetics may cause drowsiness and lack of coordination, which can be increased by the use of alcohol or other drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medications and/or drugs, or until fully recovered from their effects (this includes a period of at least 24 hours after my release from surgery). I understand that occasionally, upon injection of a local anesthetic, I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection. I understand if I select to utilize Nitrous Oxide, "Atarax", Chlorylhydrate, "Zanax", or any other sedative, possible risks include, but are not limited to, loss of consciousness, obstruction of airway, anaphylactic shock, cardiac arrest. I understand that someone needs to drive me home from the dental office after I have received sedation. I also understand that someone needs to watch me closely for a period of 8 to 10 hours, following my dental appointment, to observe for possible side effects, such as obstruction of airways.I understand that failure to take medications prescribed to me in the manner prescribed may offer risks of continued or aggravated infection and pain and potential resistance to effective treatment of my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth control pills).

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal theraphy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

I understand that popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with dental treatment are usually transitory in nature and well tolerated by most patients, I understand that should the need for treatment arise, then I will be referred to a specialist for treatment, the cost of which is my responsibility.
EXTRACTIONS OR SURGERY: I understand the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissues. The doctor has advised me that if this condition persists without treatment or surgery, my present oral condition will probably worsen in time. The potential risks include, but not limited to, the following: pain, swelling, nausea, vomiting, bruises, bleeding, tingling or numbness of the lip, gum, face or tongue, due to nerve damage, root fragments, post-operative infection, sinus complication or damage to other teeth, bone, TMJ, or neck. Alternatives to removal of teeth has been explained to me (root canal theraphy, crown and periodontal surgery, etc). I understand removing the teeth does not always remove all the infection, if present, and it may be necessary to have further treatment.
FILLINGS: I have been advised of the need for fillings, either silver or composite (plastic), to replace tooth structure lost to decay. I understand that with time fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post and build-up, and crowns), which would necessitate a separate charge. The potential risks include, but not limited to, pain, sensitivity to temperature or foods, fracture of tooth structure, nerve damage, damage to other teeth, occlusal (bite) discrepancies, and TMJ complications. I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage.
CROWNS, VENEERS,BONDING AND BRIDGES: I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur, necessitating possible root canal therapy. I understand that like natural teeth, crowns and bridges need to be kept clean, with proper oral hygiene and periodic cleanings, otherwise decay may develop underneath and/or around margins of the restoration, leading to further dental treatment. The potential risks are: pain, sensitivity, tooth nerve damage, fracture of tooth structure, damage to other teeth, bite discrepancies, tooth loss, esthetic limitations, TMJ and periodontal complications. I further understand that I may be wearing temporary crowns which may come off easily and I must be careful to ensure that they are kept on until permanent crowns are delivered. I realize that the final opportunity to make changes in my new crown, bridge or veneer (including shape, fit, size and color) will be before cementation. It is my responsibility to return for permanent cementation within 14 days after tooth preparation. Excessive delays may allow for decay, tooth movement, gum disease and/or bite problems. This may necessitate a remake of the crown, bridge or veneer. I understand there will be additional charges for remakes or other treatment due to my delaying permanent cementation.
ROOT CANAL THERAPY: The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative treatments, and the consequences of non-treatment. I understand the possibility of breakage of root canal instruments during treatment and may in the judgment of the doctor be left in the treated root canal or bone as part of the filling material, or may require surgery for removal. There is the possibility of perforation of the root canal with instruments, which may require additional surgical treatment or result in premature tooth loss or extraction. If an "open and medicate" or pulpotomy procedure is performed, I understand that this is not permanent treatment, and I need to pay for, and finish final root canal therapy. If root canal treatment is not finalized, I expose myself to infection and/or tooth loss. If failure of root canal therapy occurs, the treatment may have to be redone, root-end surgery may be required, or the tooth may have to be extracted. I understand that following root canal therapy, my tooth will be brittle and must be protected against fracture by placement of a crown (cap) over the tooth. Potential risks are pain, swelling, infection, tooth fracture, numbness of lips, face or tongue, damage to other teeth and tooth loss. I realize there is no guarantee that root canal treatment will save my tooth and that complications can occur from treatment and that occasionally, canal material may extend through the root tip which does not necessarily affect the success of the treatment. The tooth may be sensitive during treatment and even remain tender for a time after treatment.
PERIODONTAL CLEANING/SCALING (Tissue & Bone Loss): I understand that I have a serious condition, causing gum and bone inflammation and /or loss, and that it can lead to loss of my teeth and other complications. The various treatment plans has been explained to me, including gum surgery, replacements and/or extractions. I also understand that although these treatments have a high degree of success, they can not be guaranteed. Occasionally, treated teeth may require extraction. I understand that long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene ( brushing and flossing) and maintaining regular recall visits. Potential risks are pain, bleeding, gum laceration, sensitivity, swelling, infections, damage to other teeth, possible allergic reaction to fluoride treatment, nausea and vomiting. I understand that periodontal disease may have a future adverse effect on the long term success of dental restorative work.

I understand that my insurance may provide only the minimum standard of care. I understand that submitting insurance and receiving a benefit is my responsibility. I elect to follow the dentist's recommendation of optimal dental treatment.

Bleaching is a procedure done either in office (approximately 1 hour) or with take-home trays (several treatments). The degree of whitening varies with the individual. The average patient achieves considerable change (1-3 shades on the dental shade guide). Coffee, tea and tobacco will stain teeth after treatment and are to be avoided for at least 24 hours after treatment. I understand I may experience sensitivity of the teeth and/or gum inflammation, which will subside when treatment is discontinued. The Dentist may prescribe fluoride treatments for rare cases of persistent sensitivity. Carbamide peroxide and other peroxide solutions used in teeth whitening are approved by FDA as mouth antiseptics. Their use as bleaching agents has unknown risks. Acceptance of treatment means acceptance of risk. Pregnant women are advised to consult with their physician before starting treatment.

REMOVABLE DENTURES / PARTIALS: The problems of wearing dentures has been explained to me including looseness, soreness, swelling, bite discrepancies, TMJ Syndrome, dry cracked lips, gagging and possible breakage, and relining due to tissue change. Follow-up appointments are an integral part of maintenance and success of a prosthetic appliance. Persistent sore spots should be immediately examined by the doctor. I further understand that surgical intervention (i.e. tori[bone] removal, bone contouring, or implants) may be needed for dentures to be properly fitted. I also understand that due to bone loss or other complicating factors, I may never be able to wear dentures to my satisfaction. I realize that full or partial dentures are artificial, constructed of plastic, metal and/or porcelain. I realize the final opportunity to make changes in my new denture (including shape, size, fit, placement and color) will be in "teeth in wax" try - in visit. Immediate dentures (placement of dentures immediately after extractions) may be uncomfortable at first and may require several adjustments and relines. A permanent reline or second set of dentures will be necessary later. This is not included in the initial denture fee. I understand it is my responsibility to return for delivery of dentures and I understand that failure to return for delivery appointments may result in poorly fitted dentures. If a remake is required due to my delay of more than 30days, there will be additional charges.
I understand that no guarantee or assurance has been given that proposed treatment will be curative and/or successful to my complete satisfaction. I agree to cooperate completely with the recommendations of the doctor while I am under their care, realizing that any lack of same could result in less than optimum results. I certify that I have had an opportunity to read and fully understand the terms and words within the above and consent to the operation and explanation referred to or made. I have been encouraged to ask questions, and have had them answered to my satisfaction.

Signature Relationship

patient or Legal Representative


Share with your friends:

The database is protected by copyright © 2019
send message

    Main page