DENTAL TREATMENT CONSENT FORM

__X_  ____	1. WORK TO BE DONE:  I understand that I am having the following work done: Fillings ____ Bridges ____  
           (initial)	Crowns ____ Extractions ____  Local Anaesthesia ____ Root Canal(s) ____ Other __________________

__X_  ____	2. DRUGS & MEDICATIONS:  I understand that antibiotics and analgesics and other medications can cause
           (initial)	allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock, death (in rare instances).

__X_  ____	3. CHANGES IN TREATMENT PLAN:  I understand that during treatment it may be necessary to change or
           (initial)	add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures.  I give my permission to the Dentist to make any/all changes and additions as necessary.  I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results.  I acknowledge that no guarantees have been made concerning the result of dental treatment that I will receive.  

____  ____	4. REMOVAL OF TEETH / SURGERY:  Alternatives to removal have been explained to me (root canal 
           (initial)	therapy, crowns, and gum surgery) and I 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, bleeding, spread of 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 I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility. 

____  ____	5.  CROWS/BRIDGES:  I understand that sometimes it is not possible to match the color of natural teeth 
           (initial)	exactly with artificial teeth.  I 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 understand  that the temporary crown is intended to be worn for no longer than 6 weeks.  If I fail to return to the office within that time to have the final restoration placed, it may not fit. In that instance a new restoration may have to be fabricated, the cost of which is my responsibility.

____  ____	6.  ENDODONTIC TREATMENT (ROOT CANAL):  I realize there is no guarantee that root canal treatment 
           (initial)	will save my tooth, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).  

____  ____	7. PERIODONTAL LOSS (TISSUE & BONE):  I understand that I have a serious condition, causing gum and 
           (initial)	bone inflammation or loss of  my teeth.  Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions.  I understand that undertaking any dental procedures may have a future adverse affect on my periodontal condition.  

There are risks associated with any dental treatment. Some additional risks / complications that may not have been mentioned above are:
Slough (unanticipated loss of hard and/or soft tissue)	Loss of bone
Injuries to adjacent teeth and/or hard or soft tissues 	Instrument breakage
Opening between mouth and sinus or mouth and nose 	Breakage of root(s) and retained root fragments
Tooth or fragment in maxillary sinus 			Swallowing and/or aspiration of objects
Incomplete removal of tooth				Trismus (Jaw pain or difficulty opening mouth)
Loss of teeth 						Failure of treatment to accomplish its purpose

__X_  ____	All of my questions have been answered to my satisfaction.  I confirm that I have read this form or it was read 
           (initial)	to me.  I agree and consent to the treatment plan presented to me by the dentist. I understand the treatment 
options presented to me. I authorize and direct the dentist and/or associates, hygienists, assistants to perform the diagnostic, surgical or dental treatment. This consent will remain valid until revoked by me in writing.

__X_  ____	I have received a copy of the aftercare instructions for the following dental procedure(s)  Fillings ____            (initial)	Bridges ____  Crowns ____ Extractions ____  Root Canal(s) ____ Denture/Partial ____

Print Patient’s Name			Signature of Patient or Guardian					Date