Informed Consent

Treatment Plan

 I understand the recommended treatment and my financial responsibility as explained to me. I understand that by signing this consent I am in no way obligated to any treatment. I also acknowledge that 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 initial examination; for example root canal therapy following routine restorative procedures. 

Drug and Medications 

I understand that antibiotics, analgesics and other medications can cause allergic reactions such as redness and swelling tissue, pain, itching, vomiting and/or anaphylactic shock.


 I understand that there are alternatives to removal of teeth (root canal therapy, crown and bridge procedures, periodontal therapy, etc.). I understand removing teeth does not always remove 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, fractured jaw and loss of feeling in my teeth, or lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time. I understand that if complications arise I may need further treatment by a specialist at my own expense.

 Crowns, Bridges and Veneers

 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 that could come off easily and that I must be careful to ensure that they are kept on until the permanent crown is delivered. I realize the final opportunity to make changes (shape of, fit, size and color) will be before cementation. It is also my responsibility to return for permanent cementation within 20 days from tooth preparation. Excessive delays may cause tooth movement that could necessitate a remake of the crown or bridge. I understand there will be additional charges for remakes due to my delaying permanent cementation.

 Endodontic Therapy

I realize there is no guarantee that root canal treatment will save my tooth, that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth that does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments and that sometimes stresses and defects in their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts to restore it.

 Periodontal Disease

 I understand that this is a serious condition causing gum and bone inflammation and/or loss that could lead to the loss of teeth. Alternative treatments have been explained to me including gum surgery, tooth extraction and/or replacement. Fillings I understand that care must be exercised when chewing to avoid breakage of a new filling,


I understand that care must be exercised when chewing to avoid breakage of a new filling,especially during the first 24 hours. I understand that a more extensive restorative procedure than originally diagnosed from clinical observation may be required due to additional discovery of extensive decay. I understand that significant sensitivity is a common after effect of newly placed fillings and that a return visit for a bite adjustment may be necessary.

Partials and Dentures

I understand the wearing of partials/dentures can be difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of dentures immediately after extractions) may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed at a later date and is notincluded in the denture fee. I understand that it is my responsibility to return for delivery of my partial/denture. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30 days, additional charges could be incurred.

By signing below I acknowledged that dentistry is not an exact science and that reputable

practitioners cannot appropriately guarantee results. I acknowledge that no guarantee or

assurance has been made by anyone regarding the dental treatment that I have requested

and authorized.