DENTAL TREATMENT CONSENT FORM 

    Patient Name: Dated:
    1. TREATMENT

    I understand I am having the following dental treatment performed:

      1. DRUGS AND MEDICATIONS

      I voluntarily consent to the recommended drugs and medications. I understand that antibiotics, analgesics, and other medications that could cause allergies reactions, resulting in the redness and swelling of tissues, itching, pain, nauses and vomiting or more severe allergies reaction. I have informed the doctor of any known allergies.

      1. FILLINGS

      I voluntarily consent to the recommended fillings. I understand that a more extensive restoration than originally planned may be required due to additional conditions discovered during tooth preparation. I realize that fillings are rarely “ permanent” and usually require periodic replacement with additional fillings and / or crowns.

      1. CROWNS AND BRIDGES

      I voluntarily consent to the recommended crown/s and bridge/s. I have been informed that crowns, which cover the tooth, strengthen and help protect the tooth from fracture and are made of porcelain or a combination of precious metals and porcelain. I understand that a tooth can still break after being crowned. I have also been informed that bridges replace missing teeth. This is necessary in order to prevent and correct the bite or gum problems which may occur when teeth shift position.

      1. PERIODONTIAL TREATMENT

      I voluntarily consent to the recommended periodontal treatment. Periodontal disease can be a serious condition, causing gum and bone inflammation and/ or loss which may lead to loss of permanent teeth. Possible treatment plans have been explained to me, including deep cleaning, gum surgery and bone grafting, extraction of teeth and tooth replacement.

      1. CHANGES IN TREATMENT PLAN

      I understand that treatment it may be necessary to change or add procedures because of conditions discovered during treatment that were not evident during examination. I authorize my doctor to use professional judgement to provide appreciate care.

      CONSENT: I have had the opportunity to have all my questions answered by my doctor. My signature below signifies that I understand the treatment proposed to me, together with the known risks and complications associated with my treatment. I hereby give my consent for the treatment I have chosen.

       

    Patient‘s (or Legal Guardian’s) Signature

                                                  

    Date: