Please could you read and scroll down this document to submit it.
DRUGS 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.
CHANGES IN TREATMENT PLAN
I understand 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. The most common being root canal therapy following routine restorative procedures such as fillings, crowns or bridges.
DENTAL EXTRACTIONS
Alternatives 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 that there is a risk of tooth/root fracture during dental extractions and sometimes the root tips remain in the jaws. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility.
CROWN’S, BRIDGES, 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, which 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 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. I understand that there is a 15-20% risk of a healthy tooth that is prepared for a restoration needing root canal therapy as a result of this tooth preparation. If this further treatment is required I understand that the costs of such treatments is my responsibility.
ENDODONTIC TREATMENT (ROOT CANAL)
I realize 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 extend through the tooth which does not necessarily effect the success of the treatment. I understand that endodontic files and reamers are very fine instruments and 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 if I was to be 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 and/or replacement. I understand that it is my responsibility to attend my hygiene/scale & polish appointments and keep to the recall schedule that my dental healthcare professional has recommended. I accept that I am responsible for looking after my teeth and gums and risk future gum problems and likely tooth loss if I do not attend my scale and polish/periodontal therapy sessions.
FILLINGS
I understand that care must be exercised in chewing on filled teeth, especially during the first 24 hours to avoid breakage. I understand that a more extensive restorative procedure than originally diagnosed may be required due to additional or extensive decays, the most common being root canal therapy following routine restorations. I understand that significant sensitivity is a common after effect of newly placed fillings.
PARTIAL AND COMPLETE DENTURES
I understand the wearing of partials/dentures is 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. This is not included 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. I understand that dentistry is not an exact science and therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized.