I UNDERSTAND THAT TO ASSURE SUCCESSFUL TREATMENT, THIS WORK MUST BE COMPLETED IN A TIMELY MANNER ( USUALLY 6 WEEKS). 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/ procedure will be successful to my complete satisfaction. Due to individual patient differences there exists a possibility of the following risks:

1. Inability to remove overbites/ underbites.
2. Thickened or sunken lips.
3. Inability to obtain a suction, seal, or tightness of the denture or partial.
4. Sore spots that might require numerous adjustments.
5. Inability of the patient to control gagging while wearing the partial or denture.
6. Fracture/ breakage of the plate.
7. Tongue/ cheek biting.
8. Change in speech, such as lisping.
9. Inability to match natural teeth or teeth of a previous denture.

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 provided is solely responsible for his/her own patient diagnosis 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 A N OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THAT ALL BLANKS REQUIRING INSERTION WERE FILLED IN BEFORE I SIGNED.

I ALSO STATE THAT I READ AND WRITE ENGLISH.