Fillable General Dentistry Informed Consent Form printable pdf download

GENERAL DENTISTRY INFORMED CONSENT

Dentist: _________________________________

Patient: ____________________________

1. WORK TO BE DONE: I understand that I am having the following work done [Indicate all services being

provided]: Fillings ( ) Bridges ( ) Crowns ( ), X-rays ( ) Extractions ( ) Impacted teeth removal ( ) Root Canals ( )

Dentures ( ) Other ( ) ____________________.

Patient Initials ___________

DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications may

cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic

shock. I have advised my dentist of any and all medications I am currently taking, including but not limited to

prescription medications, over-the-counter medications, herbal remedies, and alternative medications. I further

understand that failure to advise that failure to advise my dentist of any medications I am taking prior to starting

to dental work may have unforeseen negative consequences for me. Patient Initials ___________

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 discoverable during

previous examinations. For example, root canal therapy may be necessary following routine restorative

procedures. I give my permission to my dentist to make any/all changes and additions as necessary.

Patient

Initials ___________

REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy,

crowns, periodontal surgery, etc.), 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 with extraction, some of which are pain, swelling, spread of infection,

dry socket, and loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an

indefinite period of time, and fractured jaw. I understand I may need further treatment by a specialist if

complications arise during or following treatment, the cost for which is my responsibility.

Patient Initials ___________

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 crowns, bridge, or cap (including shape, fit,

and color) will occur only before final cementation. It is also my responsibility to return for permanent

cementation within 21 days from initial tooth preparation. Excessive delays may allow for tooth movement

which may necessitate a remake of the crown, bridge, or cap. In such instances, I understand that there will be

additional charges for remakes due to my delaying permanent cementation.

Patient Initials ___________

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 affect 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 (apicoetomy). I understand that the tooth may be lost in spite of all efforts to save it.

Patient Initials ___________

PERIODONTAL LOSS (TISSUE AND BONE): I understand that if I am being treated for periodontal

disease, this means I have a serious condition, causing gum and bone inflammation or loss and that it can

General Dentistry Informed Consent Form

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