Dental Treatment Consent Form printable pdf download

DENTAL TREATMENT CONSENT FORM

Please read and initial items checked below

And read and sign the section at the bottom of form.

Patient Name _______________________________________

1. DIAGNOSTIC AND_PREVENTIVE

I understand that I am having the following work done: Xrays______Cleaning______ Scaling______Other_______

(Initials_____________________)

2. DRUGS AND MEDICATIONS

I understand that 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).

(Initials_____________________)

3. NITROUS OXIDE

I understand that nitrous oxide (laughing gas) provides relaxation to make it more comfortable for me to receive the

necessary dental care with less anxiety. I will be awake, fully conscious, aware of my surroundings, and able to respond

rationally. I have informed the doctor of my complete medical history including any recent surgeries or changes in my

medical history.

(Initials_____________________)

4. LOCAL ANESTHETIC

I understand there are risks of local anesthesia that may affect my body such as dizziness, nausea, vomiting, accelerated heart

rate, slow heart rate, or various types of allergic reactions. It may also cause injury to nerves that can result in pain,

numbness, tingling that may persist for several weeks, months, or rarely, be permanent. I have informed my doctor of my

complete medical history including any recent surgeries or changes in my medical history. (Initials_____________________)

5. REMOVAL OF TEETH

Alternatives to removal have been explained to me and I authorize the dentist to remove the following teeth

___________________________. I understand that removing teeth does not always remove all the infection, if present, and

it 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 that can last for

an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or

even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

(Initials_____________________)

6. CROWNS AND BRIDGES

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

understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they

are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown or

bridge will be before cementation.

(Initials_____________________)

7. DENTURES, COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial, constructed of plastic, metal and/or porcelain. The problems of wearing

these appliances have been explained to me including looseness, soreness, and possible breakage. I realize the final

opportunity to make changes in my new dentures will be the “teeth in wax” try-in visit. I understand that most dentures

require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in

the initial denture fee.

(Initials_____________________)

8. ENDODONTIC TREATMENT (ROOT CANAL)

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

treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not

necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be

necessary following root canal treatment (apicoectomy).

(Initials_____________________)

We invite you to discuss with us any questions regarding our services. The best dental health services are based on a

friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services

rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid

within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees,

collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to

perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any

information required to process insurance claims. I understand the above information and guarantee this form was

completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes

to the information I have provided. I understand that dentistry is not an exact science and that, therefore, reputable

practitioners cannot fully guarantee results. I acknowledge that no guarantee has been made by anyone regarding the

dental treatment by which I have requested and authorized. I have had the opportunity to read this form and ask

questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

Signature of patient or legal guardian _____________________________________________ Date___________________________

Dental Treatment Consent Form

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