Form

INFORMED CONSENT FOR RESTORATION, CROWNS, AND BRIDGES

This is my consent for

To perform the following treatment/ procedure:

I understand that the purpose of the procedure is to treat and possibly correct my diseased oral, maxillofacial tissues. I have been advised that if this condition persists without treatment, my preset oral condition will probably worsen in time and the risks to my health may include, but are not limited to, the following: swelling, pain, infection, caries, cyst formation, malocclusion, supraeruption of teeth, premature loss of teeth, and/or premature loss of bone. I have been informed of possible alternative methods of treatment, if any.

The Doctor has explained to me that there are certain inherent and potential risks in any treatment or procedure (including the administration of any necessary local anesthesia) which include, but are limited to:

1. Postoperative discomfort and swelling that may persist for several days.

2. Stretching of the two corners of the mouth with resultant cracking and bruising.

3. Injury to the nerve underlying the teeth resulting in numbness or tingling of the lip, chin, gums, cheek, teeth, and/or tongue on the operated side: this may persist for several days, weeks, months, or in some instances, permanently.

4. Sensitivity to filled/ crowded teeth that may necessitate root canal therapy

5. Discoloration of the gum tissue.

6. Swelling, bruising, and bleeding of the adjacent gum tissue.

7. Inability to perfectly match natural enamel with porcelain fused to metal.

8. Inability to eliminate spaces between teeth.

9. Other

I UNDERSTAND THAT FOR SUCCESSFUL TREATMENT WITH CROWNS AND BRIDGES THE WORK MUST BE COMPLETED IN A TIMELY MANNER. WE ARE NOT RESPONSIBLE FOR LAB WORK NOT DELIVERED WITHIN 90 DAYS OF LAST VISIT.

No guarantee or assurance has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. Due to the individual patient differences there exists a risk of failure, relapse, selective retreatment, or worsening of my present condition despite the care provided. However, it is the doctor's opinion that therapy would be helpful, and that a worsening of my condition would occur sooner without the recommended treatment.

I acknowledge that Dr. Behzad Nazari or Antoine Dental Center exercises no right of control over the Independent Contracted Provider's dental practice methods, procedures, tools, instruments, or execution of treatment. I agree that the Independent Contracted Provider is solely responsible for his/ her own patient diagnosis and treatment to the extent that I acknowledge that Dr. Behzad Nazari or Antoine Dental Center is not liable for any of the Independent Contracted Provider's dental practices, procedures including but not limited to the diagnosis and dental treatment performed on me. I further agree that I will hold Dr. Behzad Nazari or Antoine Dental Center harmless from any and all suits, claims, and causes of action of any matter that could be brought by the Independent Contracted Provider.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION AND THE EXPLANATION REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED.

I ALSO STATE THAT I READ AND WRITE ENGLISH

Patient or Parent

Doctor

Date

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