1. WORK TO BE DONE: I understand that I am having the following work done: Fillings    ( ), Bridges ( ), Crowns ( ), X-rays ( ). Extractions ( ), Impacted teeth removed ( ), Root Canals ( ), Dentures ( ), Other ( ).
2. DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications could cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock.
3. CHANGES IN TREATMENT PLAN: 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. For example, root canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions AS necessary.
4. LIMITED REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.) and authorize the dentist to remove the following teeth: ________________________ and any others necessary for reasons in 'paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment I understand the risks involved in having teeth removed, some of which are pain, swelling, spread or infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time or fractured jaw. I understand l may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility.
5. CROWNS, BRIDGES, AND CAPS: I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be 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. I realize the final opportunity to make changes in my new crown bridge, or cap (including shape, fit, and color) will be before cementation. It is also my responsibility to return for permanent cementation within 21 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown, bridge, or cap. I understand that there will be additional charges for remakes due to my delaying permanent cementation.
6. LIMITED ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee that root canal therapy will save my tooth, and that complications can occur from the treatment, and 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 are very fine instruments and stresses from their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts to save it.
7. PERIODONTAL LOSS (TISSUE AND BONE): I understand that I have a serious condition, causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any denial procedure may have future adverse effect on my periodontal condition.
8. FILLINGS: I understand that care must be exercising in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling.
9. DENTURES: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are some common problems. Immediate dentures (placement of denture immediately after extractions) may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline wiII be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure 10 keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of 30 days, there will be additional charges.

Consent for Sealants - I understand that the treatment of teeth through the use of sealants is a preventative measure intended to facilitate the inhibition of dental caries (tooth decay. or cavities) in the pits and fissures of the chewing surfaces of the teeth. Sealants are placed with the intention of preventing or delaying conventional restorative measures used in restoring teeth with fillings or crowns after the onset of dental caries. I agree to assume any risks that may be associated with the placement of sealants even though care and diligence will be exercised by Dr. while rendering this treatment. In addition to possible unsuccessful results and failure of the sealant, the risks of the procedure include but are not limited to the following: Preparation of the teeth: The teeth are prepared through use of an enamel etching technique. This etching is accomplished in one of two ways: a) Through the use of a special acid solution that etches the surface enamel in the area in which the-sealant is to be placed to aid in its retention. The etching solution is somewhat caustic, and if the patient makes any unexpected movement during the application process, there is the possibility that a small amount of the solution will attach to the soft tissues of the mouth, which could cause some slight tissue burns. This seldom occurs, but it is a possibility. If the etching solution contacts the root surface, the tooth may develop some temporary sensitivity. b) Through the use of a technique called "air abrasion." Air abrasion also slightly etches the surface of the enamel in the area in which sealant is to be placed to aid in the retention of the sealant. Air abrasion involves the generation of a powdery dust, which, if inhaled, could cause some discomfort. Loosening and/or dislodging of the sealant: There is the possibility of the sealant loosening or becoming dislodged overtime. The length of time over which this may happen is indeterminable because of the many variables that can impact the life of the sealant including but not limited to the following: a) The forces of mastication (chewing). These forces differ from patient to patient. The forces maybe much greater in one patient than in another. Also, the way teeth occlude (come together in chewing) may have an effect on the life of the sealants. b) The types of food or other substances that are put in the mouth and chewed. Very sticky food, including some types of gum, sticky candies such as caramels, some licorices, very hard substances, etc., can cause loosening or dislodgment of the sealant. c) Inadequate oral hygiene such as infrequent or improper brushing of the teeth also may allow leakage around and under the sealant causing it to loosen and allow decay to develop. Entire tooth is not protected with sealants: Sealants are applied primarily to the pits and fissures that are in the chewing surfaces of the teeth. These pits and fissures are extremely susceptible to decay and can be protected through the application of sealants that flow into and seal those areas. However, sealants do not protect the areas between the teeth, so thorough brushing and the use of dental floss in these areas is necessary. Otherwise, decay could develop in those areas uncovered by the sealants. Consent for Amalgam (Silver Filling) Restoration - With regards to any silver fillings that are still in good working condition, I acknowledge that it is my own choice to replace them with composite (tooth colored) fillings and that my dentist has not advised me that they need to be replaced for any health issues in the absence of 6 an allergic condition. I understand that there is no generally accepted scientific proof that replacement of silver fillings with composite tooth colored fillings will improve my health. I further understand that this is an elective procedure and that other forms of treatment, specifically including no treatment at all are additional choices that I have and I have discussed the known risks of these other forms of treatment with my dentist(s). I understand that replacement of dental amalgam with composite in a non allergic patient does not indicate that the doctor is of the opinion that amalgam is a health hazard. The doctor has explained to me that there are certain inherent and potential risks in ANY treatment plan or procedure. We do not expect these to occur, but there is that possibility. In this specific instance such risks include but are not limited to the following: a. Nerve inflammation leading to hot and cold sensitivity (and/or pain), b. The need for endodontic therapy (root canal treatment), c. Cracked cusps, d. A shorter length of serviceability of the restoration with the need for more frequent replacement. In cases where the previous restorations (fillings) are very large, the use of cast or full coverage crowns or bonded porcelain are often recommended. It has been explained to me that during the course of the procedure(s), unforeseen conditions may be revealed that may necessitate an extension of the original procedure(s) or different procedure(s) than those set forth in paragraphs above. I, therefore, authorize and request that the dentist perform such procedures as are medically necessary and desirable in the exercise of their
professional judgment. The authority granted under this paragraph shall extend to the treatment of all conditions that require treatment and are not known at the time the original procedure is commenced. . I consent to the administration of anesthesia, including local, intravenous and/or general anesthesia in connection with the procedure(s) referred to above, and to the use of such anesthetics as may be advisable with the exception of _ to which) said I was allergic. I recognize that there are always risks to life and health associated with anesthesia and such risks have been fully explained to me. Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs; thus I have been advised not to operate any vehicle, automobile, or hazardous devices or to work, while taking such medications and/or drugs, or until fully recovered from the effects of the same. I understand and agree not to operate any vehicle or hazardous device until l have recovered from the effects of the anesthetic medication and drugs Consent for Composite (Tooth colored) fillings - I understand that the treatment of my dentition involving the placement of composite resin fillings, which may be more aesthetic in appearance than some of the conventional materials that have been traditionally used, such as silver amalgam or gold, may entail certain risks. There is the possibility of failure to achieve the desired or expected results. I agree to assume those risks that may occur, even if care and diligence is exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure of the filling associated with, but not limited to, the following: Sensitivity of teeth: Often after preparation ofteeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity can be mild or severe. The sensitivity can last only for a short period of time or last for much longer periods of time. If such sensitivity is persistent or lasts for an extended period of time, I will notify the dentist because this can be a sign of more serious problems. Risk of fracture: Inherent in the placement or replacement of any restoration, is the possibility of the creation of small fracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear at a later time. Necessity for root canal therapy: When fillings are placed or replaced, the preparation of the teeth often requires the removal of tooth structures adequate to ensure that the diseased or otherwise compromised tooth structure provides sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal, which often is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required. Injury to the nerves: There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial tissues from any dental treatment, particularly those involving the administration of local anesthetics. The resulting numbness that can occur is usually temporary, but in rare instances it could be permanent. Aesthetics or appearance: When a composite filling is placed, effort will be made to closely approximate the appearance of natural tooth color. However, because many factors affect the shades of teeth, it may not be possible to exactly match the tooth coloration. Also, the shade of the composite fillings can change over time because of a variety of factors including mouth fluids, foods, smoking, etc. The dentist has no control over these factors. Breakage, dislodgement or bond failure: Because of extreme masticatory (chewing) pressures or other traumatic forces, it is possible for composite resin fillings or aesthetic restorations bonded with composite resins, to be dislodged or fractured. The resin-enamel bond can fail, resulting in leakage and recurrent decay. The dentist has no control over these factors.

I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the denial treatment which I have requested and authorized. I hereby authorize any of the doctors or dental auxiliaries to proceed with and perform the dental restorations and treatments as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any denial insurance coverage I may have, I am responsible for payment of the dental fees. I agree to pay any attorney's fees, or court costs, that may be incurred to satisfy this obligation.

I am aware that alternative treatments/procedures may be available, as well as the option not to proceed with the recommended treatment/procedure. I also understand that there are inherent risks to this recommended treatment/procedure as well as to any alternate treatment/procedure, as well as postponing___ or declining this recommended treatment/procedure. Those risks may include but are not limited to:
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In addition, my dentist or his/her staff has offered me a more detailed explanation of this recommended treatment/procedure-if I so desire. I am fully satisfied with the description and information given, and all my questions/concerns have been satisfactorily answered. I acknowledge that no guarantee or warranty has been made to me about the results of any of the above recommended choices. Therefore, I freely give my consent to this above recommended treatment/ procedure.