General Dentistry Informed Consent Form (Page 2 of 2) in pdf

It may be sore, temperature sensitive or pressure sensitive for several weeks. The position of my teeth is dynamic

condition therefore bite adjustments may be required following the restorations.

CROWNS/ INLAYS/ ONLAYS/ BRIDGES!

I understand that sometimes it is not possible to match the color of the artiﬁcial teeth exactly to natural teeth. Most of

the time my dentist will give me an option of having the shade taken in the laboratory under the different light sources.

I further understand that I may be wearing temporary crowns/ ﬁllings that may come off easily and I must be careful to

ensure that they are kept on until the permanent crown is delivered. I realize that the ﬁnal opportunity to make

changes to my restoration ( including shape, size, ﬁt and color) will be before cementation. It is also my responsibility

to return for permanent cementation within 20 days from the preparation date. Excessive delays may allow for tooth

movement. This may necessitate a remake of the crown or bridge. I understand there will be an additional charge for

remakes due to me delaying permanent cementation. I also understand that I may require root canal therapy after

routine crown/ inlay/ onlay/ bridge preparation It will be determined by my health care provider at the time of

presenting symptoms if further treatment with root canal therapy is required.

ENDODONTIC TREATMENT (ROOT CANAL THERAPY)!

I understand that there is no guarantee that root canal treatment will save my tooth, and the complications can occur

from the treatment. Occasionally root canal ﬁlling materials may extend through the the tooth, which does not

necessarily, affect the success of treatment. I understand the endodontic ﬁles and reamers are very ﬁne instruments;

stresses vented in their manufacture can cause them to separate or break during use. I understand that sometimes

additional surgical procedures or re-treatment may be necessary following root cal treatment. I understand that the

tooth may be lost in spite of all the efforts to save it. Root canal treated teeth must be covered by crowns or bridges

and if I do not follow the post-operative instructions, it could lead to a fracture and failure of root canal treated tooth.

DENTURES AND PARTIALS!

I understand that wearing dentures or partials may be difﬁcult. Sore spots, altered speech and difﬁculty eating are

common problems. Immediate dentures (placed right after surgery/ extractions) may be painful and may require

considerable adjustments and several relines. Regular follow up is necessary to maintain soft tissue health and

optimized healing. A permanent reline will be needed later. This is not included in the denture fee. I understand that

this is my responsibility to return for delivery of dentures and follow up appointments. I understand that failure to keep

my appointment may result in poor ﬁtting dentures or partials. If a remake is required due to my delay of more than 30

days, there will be an additional charge.

ORTHODONTICS!

Our doctors are experienced/ trained in the provision of Invisalign orthodontic treatment. It is the patients

responsibility to be 100% compliant with instructions and homecare for the treatment to be successful. I understand

that additional fees maybe applied if reﬁnement of the treatment is needed. The cost of the retainers are not included

in the initial invisalign treatment fee.

AKNOWLEDGMENT!

I certify that the answers to the health questionnaire are accurate and correct to the best of my knowledge. Since a

change of medical conditions, pregnancy or medications can affect dental treatment, I understand the importance of

and agree to notify Dr. Osmolinski and Associates of any changes at any subsequent appointment.!

I understand that dentistry is not an exact science and therefore reputable practitioners cannot guarantee results. I

acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment I have

requested and authorized.!

I hereby authorize Dr. Osmolinski and Associates and dental auxiliaries to proceed with and perform the dental

procedures and treatments as had been explained to me. I understand this is only an estimate and subject to

modiﬁcation depending on unforeseen or undiagnosable circumstances that may arise during the course of

treatment. I understand that regardless of any insurance coverage I may have, I am responsible for payment of dental

fees. I agree to pay any attorney's fees, collection fees, or court costs that may incurred to satisfy this obligation.!

________________________

___________________________

! ___________!

Patient Name PRINT

Patient Signature

Date

General Dentistry Informed Consent Form Page 2

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