TREATMENT TO BE DONE: I understand and consent to have any treatment done by the dentist after the procedure. The risks and benefits and cost have been fully explained. These treatments include, but are not limited to, x-rays, cleaning, periodontal treatment, fillings, crowns, bridges, all types of extraction, root canals, and/or
dentures, local anesthetics and surgical cases.
DRUGS & MEDICATIONS: I understand that antibiotics, analgesics and other medications can cause allergic reactions like redness and swelling of tissues, pain, itching, vomiting, &/or anaphylactic shock.
CHANGES IN TREATMENT PLAN: I understand that during treatment it maybe necessary to change/ add procedures because of conditions found while working on the teeth that was not discovered during examination. For example, root canal therapy may be needed following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary with my responsibility to pay all the costs agreed.
RADIOGRAPH: I understand that an x-ray shot or a radiograph maybe necessary as part of diagnostic aid to come up with tentative diagnostic of my Dental problem and to make a good plan, but this will not give me a 100% assurance for the accuracy of the treatment since all dental treatments are subject to unpredictable compilations that later on my lead to sudden changes & additions as necessary with my responsibility to pay all the costs agreed.
REMOVAL OF TEETH: I understand that alternatives to tooth removal (root canal therapy, crown & periodontal surgery, etch.) & I completely understand these alternatives, including their risk and benefits prior to authorizing the dentist to remove teeth and any other structure necessary for reasons above. I understand that removing teeth does not always remove all infections. If present, & it maybe necessary to have further treatment. I understand the risk involved in having teeth removed, such as pain, swelling, spread of infection, dry socket,
fractured jaw, loss of feeling on the teeth, lips tongue and surrounding tissue that can last for an indefinite period of time. I understand that I may need further treatment under a specialist if complications arise during or following treatment.
CROWNS(CAPS) & BRIDGES: Preparing a tooth may irritate the nerve tissue in the center of the tooth, leaving the tooth extra sensitive to heat, cold & pressure. Treating such irritation may involve using special toothpastes, mouth rinses or root canal therapy. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I maybe 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. It is
my responsibility to returned for permanent cementation within 20 days from tooth preparation, as excessive days delay may allow for tooth movement, which may necessitate a remake of the crown, bridge/cap. I understand there will be additional charges for remakes due to my delaying of permanent cementation, and I realize that final opportunity to make changes in my new crown, bridges or cap (including shape, fit, size, and color) will be before permanent cementation.
ENDODONTICS (ROOT CANAL): I understand there is no guarantee that a root canal treatment will save a tooth and that compilations can occur from the treatment & that occasionally root canal filling material may extend through the tooth which does not necessarily effect the success of the treatment. I understand that endodontic files and drills are very fine instruments & stresses vented in their manufacture and calcifications present in teeth can cause them to break during use. I understand that referral to the endodontist for additional treatments may
be necessary following any root canal treatment & I agree that I am responsible for any additional cost for treatment performed by endodontist. I understand that a tooth may required removal in inspire of all efforts to save it.
PERIODONTAL DISEASE: I understand that periodontal disease is a serious condition causing gum and bone inflammation &/or loss and that can lead eventually to the loss of my teeth. I understand the alternative treatment plans to correct periodontal disease, including gum surgery tooth extraction with or without replacement. I understand that undertaking any dental procedures may have future adverse effect on my periodontal conditions.
FILLINGS: I understand that care must be exercised in chewing on fillings, during the first 24hours to avoid breakage. I understand that a more extensive filling or crown may be required, as additional decay or fracture may become evident after initial excavation. I understand that significant sensitivity is a common, but usually temporary, after – effect of a sensitivity could require root canal therapy or extractions.
DENTURES: I understand that wearing of dentures can be difficult. Sore spots, speech &difficulty in eating are common problems. Immediate denture (placement of denture immediately after extractions) maybe painful. Immediate denture may require considerable adjusting and several relines. I understand that it is my responsibility to return for delivery of dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30 days, there will be additional charges. A
permanent reline will be needed later, which is not included in the initial fee. I understand that all adjustment or alteration of any kind this initial period is subject to charges.
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