any of the following Treatment(s), as discussed by the Doctor:
Exam, Prophy, Fluoride, X-Rays, Silver or White Fillings, Silver Crowns, White Crowns, Nerve Treatments, Extractions, Spacers, Crown and Bridge, dentures (partial or complete)  

Dr. Diba Dastjerdi or an associate will perform 1 or more of above dental procedures and any additional procedures that are considered necessary during my/my child's treatment.

The Doctor has explained the treatment/procedure(s) including the purpose of the procedure, and possible alternatives. He/She has also advised me of the possibility of complications, the expected consequences of the treatment/procedures, and the possible results of non-treatment.

No one has guaranteed any specific result of the treatment/procedure(s).

I understand that the doctors may discover medical conditions that they did not know about that require a change in the procedure, a more extensive procedure, or a different procedure. Knowing this, I authorize the doctor to perform the procedure(s) that in their best judgement are necessary or wise for the well-being of me or my child.

My Signature on this form shows that (1) I have read and understand the information on this form, (2) the treatment/procedure(s) described and discussed above have been satisfactorily explained to me, and that there is no guarantee the dental procedure will be successful and infection, extraction, or root canal may be needed after this treatment is completed, (3) I have had a chance to ask questions and can do so the day of the procedure, including alternative treatments as well as advantages and disadvantages of each, including no treatment (4) I have been given all of the information I desire concerning the treatment/procedure(s), (5) I consent to the performance of the treatment/procedure(s),