General Dentistry Informed Consent Form Page 2
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2ultimately 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 any dental procedure may have a future adverse effect
on my periodontal condition.
Patient Initials ___________
8.
FILLINGS: I understand that care must be taken when 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 increased sensitivity is a common effect of a newly placed filling.
Patient Initials ___________
9.
DENTURES: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty
in eating are common problems associated with dentures. Immediate dentures (placement of denture immediately
after extractions) may be painful. In addition, immediate dentures often require considerable adjusting and
several relines. A permanent reline will 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 to keep my delivery
appointment may result in poorly fitted dentures. If a remake is required due to my delay of 30 days or more,
there may be additional charges assessed against me.
Patient Initials ___________
I understand that dentistry is an inexact science and that therefore, reputable practitioners cannot properly
guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the
dental treatment(s) which I have requested and authorized.
I hereby authorize any of the doctors or dental assistants or auxiliaries to proceed with and perform the dental
restorations and treatments indicated above and as explained to me. I understand that this is only an estimate and
subject to modification depending on unforeseen or undiagnosed circumstances that may arise during the course
of treatment. I understand that regardless of any dental insurance coverage I may have, I may be responsible for
payment of the dental fees.
Signature of Patient: ______________________________
Date: __________________
Signature of Dentist: ______________________________
Date: __________________
GENERAL DENTISTRY INFORMED CONSENT
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