General Dentistry Informed Consent Form printable pdf download

9450 Scranton Rd. #109,

San Diego, CA 92121

(858) 457-8514

GENERAL DENTISTRY INFORMED CONSENT FORM

TREATMENT PLAN!

I understand that I may be having the following work done but not limited to: Fillings, Periodontal treatment, Crowns/

Inlays/ Onlays, Extractions, Root Canals ,Dentures, X Rays, Surgery, Implants and or

Other_________________________________________ .!

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 the examination. For example, root canal therapy following

routine restorative procedures. I give permission to Dr. Osmolinski and Associates to make any changes and

additions necessary.!

DIAGNOSIS!

I understand that diagnostic procedures can involve several appointments/ multiple radiographic images and in

complex cases an additional specialist examination may be required to develop a comprehensive treatment plan. !

DRUGS AND MEDICATIONS!

I understand that antibiotics, analgesics and/ or other medications can cause allergic reactions, redness, swelling,

pain, itching, and/or anaphylactic shock. It is my responsibility to inform my treating practitioner about any possible

allergies I may have.

LOCAL ANESTHESIA!

I understand that local anesthesia is recommended for most of the procedures performed and its beneﬁts far

outweigh the potential risks, however I am aware that it can result in allergic reaction and life threatening anaphylactic

shock. Furthermore, it can result in permanent damage to the nerve, partial or complete permanent numbness lasting

several days to months, bruising or formation of hematoma.!

! !

PREVENTATIVE TREATMENT!

I understand that my dentist may recommend alternative approaches for optimization of my dental/ overall health,

including but not limited to nutritional counseling/ tobacco counseling/ oral hygiene instructions/ ﬂuoride treatment. !

WHITENING TREATMENT!

There may be sensitivity associated with the whitening procedures done in the ofﬁce (zoom) and at home (trays,

strips, pen). It is a common consequence of whitening. Patient is advised to take analgesics and treat the area with

topical ﬂuoride until sensitivity subsides.!

PERIODONTAL CLEANING/ SCALING AND ROOT PLANING!

I understand that the most common complications are pain, bleeding, tissue (gum) laceration, sensitivity to

temperature or foods, swelling, ulceration (infection), tooth fracture, breaking of ﬁllings, dislodging of crowns or

veneers. Reaction to ﬂuoride treatment may cause nausea or vomiting.!

PERIODONTAL LOSS (TISSUE AND BONE)

I understand that I may have a serious condition, causing gum inﬂammation, bone loss, and it can lead to the loss of

my teeth. Alternative treatment plans have been explained to me, including gum surgery, bone grafts,, extractions,

laser treatment and bacterial irrigation. Any dental procedures may have future adverse effects on my periodontal

condition.!

RESTORATIVE TREATMENT!

I understand that the most common complications are pain, sensitivity to temperature, fracture of tooth, nerve

damage, damage to other teeth, occlusal (bite) discrepancies, TMJ complications, reactions to drugs/ anesthesia. I

understand that sometimes existing caries may cause inﬂammation of the nerve and subsequently ﬁlling restorations

may have to be further treated by a root canal therapy due to initial underlined inﬂammation of the nerve. Also I

understand that once the tooth is restored with a ﬁlling material it is never going to feel the same as natural tooth.!

General Dentistry Informed Consent Form

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