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

separate from our service fees. This process involves several steps and could last

from 2-6 months before complete (depending on healing time needed). As with

crowns, color may not match perfectly with natural teeth.

9. Sealants: There is no guarantee that a sealant will prevent all cavities. They do,

however, form a hard shield that keeps food and bacteria from getting into tiny

grooves and causing decay along the chewing surfaces of the back teeth.

Occasionally sealants need to be replaced, since they do not last a lifetime. We do,

however, warranty our sealants for 2 years as long as the patient is seen twice a year

for prophylaxis visits. Sealants can be done at any age as long as the teeth are free

of decay and ﬁllings. The doctor will determine the best time to have them done.

10. Sedative Fillings: Sedative ﬁllings are temporarily. They are placed if near caries

exposure of the nerve is suspected. If the tooth becomes symptomatic after 4-6

weeks, itʼs likely the tooth will need a root canal or it may need to be extracted. If the

tooth is asymptomatic after 4-6 weeks, than the root has not been exposed. The

sedative ﬁlling allows the tooth to lay down reparative dentin and will enable the

Doctor to remove the decay and restore the tooth.

Treatment risk: 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, pulp necrosis.

Most of the symptoms usually resolve as the nerve heals."Complications may arise

resulting in the need for additional treatment. This may include one or more bite

adjustments, replacement of the restoration due to open margins discovered after ﬁnal

cementation, root canal treatment or tooth removal.

I have carefully read above conformed consent and fully understand all risks as it

relates to my case.

Patient Signature____________________________________________

Date_______________________

General Dental Informed Consent Form Page 2