General Dental Informed Consent Form


Dr. Stansell would like all of her patients to have knowledge of risks and benefits of
dental procedures. We ask that you review the procedures listed and feel free to ask
any questions. A treatment plan for all restorative work, which includes estimated fees
and treatment specific authorization, will be presented to you for your review and
signature at the time treatment is recommended.
Drugs and Medication: 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.) Risk of local
anesthesia may include temporary or permanent numbness or bruising.
Changes in Treatment: 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, the most common being root canal therapy
following routine restorative procedures.
Removal of Teeth: Alternatives will be explained to you (root canal therapy,
crowns, and periodontal surgery, etc.) The removal of teeth does not always
remove all the infection, if present, and it may be necessary to have further
treatment. Some of the risks are pain, swelling, spread of infection, dry socket,
loss of feeling in teeth, lips, tongue and surrounding tissue (paresthesia) that can
last for an indefinite period of time (days or months) or fractured jaw. Further
treatment by a specialist or even hospitalization if complications arise during or
following treatment would be your responsibility.
Crown, and Bridges : Sometimes it is not possible to match the color of natural
teeth exactly with artificial teeth. You may wear temporary crowns, which may
come off easily. You will need to be careful to ensure that they are kept on until the
permanent crowns are delivered. The final opportunity to make changes to a new
crown, or bridge (including shape, fit, size, or color) must be done at the
preparation appointment.
Partials: They are artificial, constructed of plastic, metal and/or porcelain. The
problem of wearing these appliances, including looseness, soreness, and possible
breakage Most partials require relining approximately three to twelve months after
initial placement. The cost for this procedure is not included in the initial fee.
Endodontic Treatment (Root Canal): There is no guarantee that root canal
treatment will save a tooth. Complications can occur from the treatment and
occasionally metal objects are cemented in the tooth or extend through the root,
which does not necessarily affect the success of the treatment. Occasionally
additional surgical procedures may be necessary following root canal treatment
Periodontal Loss (Tissue & Bone): This is a serious condition, causing gum and
bone infection or loss and can lead to the loss of teeth. Alternative treatment will
be explained to you (gum surgery, replacements, and/or extractions). Any dental
procedure may have a future adverse effect on your periodontal condition.
Implants: They are a permanent alternative to bridges, partials or dentures. This
process involves the participation of an oral surgeon. Fees for his/her services are


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