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 examination. For example, root canal therapy following routine restorative procedures.

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

Alternative to removal of teeth have been explained to me (root canal therapy, crown and bridge procedures, periodontal therapy, etc.). I understand removing teeth does not always remove the infection, if present, and 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, loss of feeling in my teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time, or fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility.

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, which come off easily and that I must be careful to ensure that they are kept on until the permanent crown is delivered. I realized 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 the tooth preparation. Excessive delays may allow for tooth movement. This may 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 that there is no guarantee that root canal treatment will save my tooth,and that complications can occur from the treatment, and that occasionally root canal filling material may extent through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments 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 effort to restore it.

PERIODONTAL DISEASE
I understand that I have been diagnosed with a serious condition, causing gum and bone inflammation and/or loss and that the result could lead to the loss of teeth. Alternative treatments have been explained to me, including gum surgery, tooth extraction/or replacement.

I understand that care must be exercised in chewing on filling teeth, especially during the first 24 hours to avoid breakage. I understand that a move extensive restorative procedure than originally diagnosed may be required due to additional or extensive decays. I understand that significant sensitivity is common after effect of newly placed fillings.

PARTIALS AND DENTURES
I understand the wearing of partials/dentures is difficult, Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures 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. 


I Understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot property guarantee results. I acknowledge that no guarantee or assurance has  been made by anyone regarding the dental treatment, which I have requested and authorized.