Download Consent to Treatment

New Smiles Studio
General Informed Consent to Treatment
12137 Magnolia Boulevard
Patient name_____________________________
Date____________________________________
Valley Village, CA 91607
In reading and signing this form, it is understood that ENGLISH is the language that I understand and use to communicate.
Initials_________
[ ] 1. DRUGS, MEDICATIONS, AND ANESTHESIA
I understand that antibiotics, analgesics, and other types of medications may cause adverse reactions, some of
which include, but are not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, cardiac arrest, and
anaphylactic shock and death.
I understand that occasionally, upon injection of a local anesthetic, I may have prolonged, persistent anesthesia,
numbness, altered sensation, bruising, and/or irritation to the area of injection. a potential risk local anesthesia may
include temporary or permanent numbness or bruising.
Initials_______
[ ] 2. 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 teeth that were not discovered during examination. For example: root canal therapy following
routine restorative procedures. I give my permission to the dentist to make any/all changes and additions that are
necessary for my treatment.
Initials_______
[ ] 3. PERIODONTAL DISEASE
I understand that I have a serious condition, causing bone loss and gum inflammation that can lead to the loss of
my teeth. The various treatment options have been explained to me, including subgingival curettage and root planing
(deep scaling and removal of calculus in periodontal pockets), Osseous and Mucogingival surgery (bone and gum
surgery), removal of teeth and the replacement of them. I understand that undertaking any dental treatment to try to
save my teeth may have future adverse effects on my periodontal condition, and that the teeth may be lost in spite of
any effort to save them.
I understand that the long term success of treatment and the status of my oral condition depend on my efforts
at proper oral hygiene (i.e. brushing and flossing) and maintaining regular hygiene maintenance visits. Initials_______
[ ] 4. FILLINGS
I have been advised of the need for fillings to replace tooth structure lost to decay. I understand that care should
be exercised while chewing on fillings during the first 24 hours of placement to avoid breakage. I understand that with
time fillings will need to be replaced due to wearing of the materials. It was explained to me that in cases where
additional decay was not visible on the x-ray at the time of diagnosis (examination), very little tooth structure remains,
or existing tooth structure fractures off, I may need to receive more extensive treatment (i.e. root canal therapy, buildup, or crowns), which would necessitate a separate charge. I understand that significant sensitivity is common after a
new filling is placed, and that the sensitivity could last for a long period of time.
Initials_______
[ ] 5. SEDATIVE FILLINGS
I understand that sedative fillings are temporary. They are placed if caries exposure of the nerve is suspected. If
the tooth becomes symptomatic after 4-6 weeks, it is likely the tooth will need a root canal or it may need to be
extracted. If the tooth is asymptomatic after 4-6 weeks, then the nerve has not been exposed and the tooth may not
require root canal treatment. The sedative filling allows the tooth to repair itself (lay down reparative dentin) and will
enable the Dentist to remove the decay and place a final restoration on the tooth.
Initials_______
[ ] 6. ROOT CANAL THERAPY (ENDODONTICS)
The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative
treatments, and the consequences of non-treatment. I understand that following root canal therapy my tooth may be
brittle and require the placement of a crown (cap) over the tooth to protect against fracture.
I understand there is no guarantee that root canal treatment 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 and reamers are very fine instruments
and stresses and defects in their manufacture can cause them to separate during use. I understand that occasionally
additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand that the
tooth may be lost in spite of all efforts to restore it. (An additional consent form will be necessary should I require Root
Canal Therapy).
If an “open and medicate” or pulpotomy procedure is performed, I understand that this is not the permanent
treatment, and I must return to pay for and finish the final root canal therapy. I understand that if I do not return for
root canal completion, I risk exposing myself to infection and/or tooth loss.
Initials_______
[ ] 7. REMOVAL OF TEETH (EXTRACTION)
I understand that the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissues. The
doctor has advised me that if this condition persists without treatment or surgery, my present oral condition will likely
worsen in time. Alternatives to removal of teeth have been explained to me (root canal therapy, crown and bridge
procedures, periodontal therapy, etc.). I understand removing teeth does not always remove the infection, if present,
and may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of
which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue
(paresthesia) that can last for an indefinite period of time, fractured adjacent teeth or fractured jaw. I understand I may
need further treatment by a specialist if complications arise during or following treatment. (An additional consent form
will be necessary should I require the removal of teeth).
Initials_______
[ ] 8. CROWNS, BRIDGES AND CAPS
I understand that sometimes it is not possible to match the exact shape, size, fit or color of the natural teeth
with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur,
necessitating possible root canal therapy. I further understand that I will be wearing a temporary crown, which may
come off easily. I must be careful to ensure that they are kept in place until the permanent crowns are delivered. I
realize that the final opportunity to make any changes in my new crown, bridge or cap including shape, size, fit and
color, will be before cementation. It is also my responsibility to return on time for my cementation within 30 days from
the tooth preparation. Excessive delay may allow teeth movement, which may necessitate remaking the crown, bridge
or cap, in which case I will be responsible for any additional charges due to my delaying permanent cementation.
I understand that like natural teeth, crowns and bridges need to be kept clean, with proper oral hygiene and
periodic cleaning, otherwise decay may develop underneath and/or around the margins of the restoration, leading to
further dental treatment.
Initials_______
[ ] 9. DENTURES AND PARTIAL DENTURES
I understand that wearing dentures is difficult. It was explained to me that I could experience sore spots, altered
speech, and difficulty chewing, and that these are common problems. Immediate dentures (placement of a denture
immediately after the extractions) may be painful and will require considerable adjustments and several relines. In
addition, a permanent laboratory reline will be needed at a later date. I understand that it is my responsibility to return
on time for my appointments during the making of the dentures and for delivery of dentures. Failure to do so may result
in poorly fitted dentures, and if a remake is required due to my delays any additional charges will be my responsibility.
An additional consent form will be necessary should I require a denture).
Initials_______
[ ] 10. IMPLANTS
I understand that implants are a permanent alternative to bridges, partials or dentures. This process may involve
the participation of an oral surgeon. This process involves several steps and could last from 2-12 months before
completion (depending on healing time needed). As with crowns, bridges and caps the color, shape, size, and fit may not
match perfectly with natural teeth. (Ad additional consent form will be necessary should I require an implant). Initials__
[ ] 11. TREATMENT RISKS
I understand that any time a restoration is performed there is a possibility of trauma to the nerve of the tooth,
which could result in varying degrees of sensitivity and complications including but not limited to the following: cold
sensitivity, hot sensitivity, biting sensitivity, abscess, and pulpal necrosis. Most of the symptoms usually resolve as the
nerve heals. Complications may arise resulting in the need for additional treatment. This may include, but are not limited
to one or more bite adjustments, replacement of the restoration due to open margins discovered after final
cementation, root canal treatment or tooth removal.
Initials_______
[ ] 12. GUARANTEE
I understand that dentistry is not an exact science and therefore reputable practitioners cannot properly
guarantee results. I acknowledge that no guarantee of assurance has been made by anyone regarding this dental
treatment, which I have requested and authorized. I understand that each Dentist is an individual practitioner and is
individually responsible for the dental care rendered to me. I also understand that no other Dentist nor Dental group or
Laboratory, are responsible for my dental treatment.
Initials_______
I certify that I have had an opportunity to read and fully understand the terms and words above and in the
previous pages of this document, and consent to the operation and explanation referred to or made. I have been
encouraged to ask questions and have had them answered to my satisfaction. I agree that a photocopy of this
authorization shall be valid and effective as the original forever. I am of legal age and legally competent to make this
assignment for myself or for any of my dependents.
I understand that Melanie Washington, D.D.S., Inc. provides dental care services without discrimination
based on race, religion, color, national origin, sex, sexual orientation, physical or mental disability, age, marital status
and protects the privacy of each of its patients.
I hereby authorize any of the doctors or dental auxiliaries of New Smiles Studio to proceed with and perform
the dental treatment that was explained to me. I understand that this is only an estimate of treatment and subject to
modification depending on unforeseen or undiagnosable circumstances that may arise during the course of
treatment. I understand my dental coverage of benefits. Should any dispute arise over dental services provided to
me, that is whether any dental service rendered as allegedly unnecessary, unauthorized or was improperly,
negligently, or incompetently performed, said will be submitted to peer review by the local component of the
American Dental Association. The decision of Peer Review shall be binding on both parties.
Signature: Relationship:________________ Date________________
Patient or Legal Representative
Doctor Signature_________________________________
Witness_______________________________________