General Dental Informed Consent Form printable pdf download

GENERAL DENTAL INFORMED CONSENT FORM

Dr. Stansell would like all of her patients to have knowledge of risks and beneﬁts of

dental procedures. We ask that you review the procedures listed and feel free to ask

any questions. A treatment plan for all restorative work, which includes estimated fees

and treatment speciﬁc authorization, will be presented to you for your review and

signature at the time treatment is recommended.

Drugs and Medication: Antibiotics and analgesics and other medications can

cause allergic reactions causing redness and swelling of tissues, pain, itching,

vomiting, and/or anaphylactic shock (severe allergic reaction.) Risk of local

anesthesia may include temporary or permanent numbness or bruising.

Changes in Treatment: 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, the most common being root canal therapy

following routine restorative procedures.

Removal of Teeth: Alternatives will be explained to you (root canal therapy,

crowns, and periodontal surgery, etc.) The removal of teeth does not always

remove all the infection, if present, and it may be necessary to have further

treatment. Some of the risks are pain, swelling, spread of infection, dry socket,

loss of feeling in teeth, lips, tongue and surrounding tissue (paresthesia) that can

last for an indeﬁnite period of time (days or months) or fractured jaw. Further

treatment by a specialist or even hospitalization if complications arise during or

following treatment would be your responsibility.

Crown, and Bridges : Sometimes it is not possible to match the color of natural

teeth exactly with artiﬁcial teeth. You may wear temporary crowns, which may

come off easily. You will need to be careful to ensure that they are kept on until the

permanent crowns are delivered. The ﬁnal opportunity to make changes to a new

crown, or bridge (including shape, ﬁt, size, or color) must be done at the

preparation appointment.

Partials: They are artiﬁcial, constructed of plastic, metal and/or porcelain. The

problem of wearing these appliances, including looseness, soreness, and possible

breakage Most partials require relining approximately three to twelve months after

initial placement. The cost for this procedure is not included in the initial fee.

Endodontic Treatment (Root Canal): There is no guarantee that root canal

treatment will save a tooth. Complications can occur from the treatment and

occasionally metal objects are cemented in the tooth or extend through the root,

which does not necessarily affect the success of the treatment. Occasionally

additional surgical procedures may be necessary following root canal treatment

(apicoectomy).

Periodontal Loss (Tissue & Bone): This is a serious condition, causing gum and

bone infection or loss and can lead to the loss of teeth. Alternative treatment will

be explained to you (gum surgery, replacements, and/or extractions). Any dental

procedure may have a future adverse effect on your periodontal condition.

Implants: They are a permanent alternative to bridges, partials or dentures. This

process involves the participation of an oral surgeon. Fees for his/her services are

General Dental Informed Consent Form