Crowns, Onlays/Inlays, Bridges, Veneers, and Bonding: Sometimes it is difficult or impossible to exactly match the color of artificial teeth or restorative materials with natural teeth. Although the dentist will provide assistance, it is my responsibility to make any changes (including shape, size, and color) before permanent cementation. Failure to do so will result in additional fees. After a temporary crown has been placed, it is essential to have the new crown cemented as soon as it is ready, because the temporary crown is not intended to function as a permanent restoration. Failing to replace the temporary crown could lead to decay, gum disease, infections, problems with the bite, and even loss of the tooth. (Further, if there is a prolonged delay in placing the permanent crown, it may no longer fit properly.)

Changes in Treatment Plan: During the course of treatment, procedures may need to be added, expanded, or changed if the dentist finds conditions that were not identified during examination and were first observed during the course of treatment. The most common scenarios include the need for root canal therapy, extraction, or more extensive restorative services that the dentist determines to be necessary. Further, at the dentist’s discretion, I may be referred to a specialist for further treatment, the cost of which may be my responsibility.

Drugs, Medications, and Sedation: Drugs, medication, or anesthesia/sedation can cause allergic and other reactions. Examples include, but are not limited to, swelling, redness, itching, vomiting, diarrhea, and numbness or tingling of the lip, gum, or tongue (which in rare cases may be permanent), as well as, in rare cases, anaphylactic shock. Since drugs, medications, or anesthesia/sedation also may cause drowsiness and impair coordination or awareness, patients should not operate a motor vehicle or hazardous device before achieving full recovery. I have informed the dentist of all drugs and medications I am taking or have taken within the last 30 days, as well as those that have been prescribed within the last six months and of all allergies and sensitivities of which I am aware. I have been informed and understand that failure to take drugs or medications as prescribed by my dentist may result in continued aggravated infection and pain, and resistance to effective treatment. I also understand that antibiotics can reduce the effectiveness of birth control pills.

I have discussed treatment alternatives, risks, outcomes, and costs with my dentist and have had all of my questions answered before making a decision. I understand that dentistry is not an exact science and that there are no guaranteed results. Unless otherwise provided by law, I understand that I am responsible for payment of all dental fees not paid in full by any insurance or other applicable coverage.

Having had adequate time to reflect upon alternatives, I consent to the treatment, which is subject to changes in the treatment plan, as detailed above.