General Consent Form - Richland Dentistry, Plc printable pdf download

General Consent Form

Patient name: ________________________________________________________

Please read this form before you sign it.

Medical History Information

Please understand that it is important that you give all information about your medical

history to your provider. It is important that you inform us of any medicines that you are

taking each time that you come to an appointment, as some medications can cause

harmful reactions with dental anesthetics, analgesics, antibiotics or with other

medications. Please be sure to provide us with a list of any allergies.

Restorations (Fillings and Crowns)

I understand that care must be exercised in chewing on fillings and crowns until directed

by the doctor or staff to avoid breakage or soft tissue damage. I understand that a more

extensive filling than originally diagnosed may be required due to additional decay or the

condition of remaining tooth structure. I understand that sensitivity may occur after a

newly placed filling or crown. I also have been informed that in some cases, root canal

treatment may be required following a restoration. I realize that a large filling may not be

a good long term solution and may lead to tooth breakage that will require further

treatment.

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 discovered during

examination. For example, root canal therapy may be necessary following routine

restorative procedures. Also, a filling may be extended to cover additional surfaces if

deemed necessary due to decay or fractures not evident upon the original examination. I

give my permission to the dentist to make any/all changes and additions as necessary

after consultation.

Complications

Although rare, complications can occur from the use of dental instruments, drugs,

sedation, medicines, analgesics (pain killers), anesthetics, and injections include (but are

not limited to) swelling, sensitivity, bleeding, pain, infection, numbness and tingling

sensation in the lip, tongue, chin, gums, cheeks, and teeth (which is transient but on

infrequent occasion, may be permanent), reaction to injections, changes in occlusion

(biting), jaw muscle cramps and spasms, temporomandibular (jaw) difficulty, referred

pain to ear, neck, and head, nausea, vomiting, allergic reactions, delayed healing and

treatment failure. The risks of complications from medications used/prescribed with

general dental treatment include, but are not limited to, drowsiness, lack of awareness and

coordination, nausea, allergic reactions, etc. (which may be influenced by the use of

Initial __________

General Consent Form - Richland Dentistry, Plc