PATIENT CONSENT TO TREATMENT

In reading and signing this form it is understood that ENGLISH is the language that I understand and use to communicate.

     I understand that antibiotics, analgesics, and other medication may cause adverse reactions, some of which are, but are notlimited to redness and swelling of tissues, pain. Itching, vomiting, dizziness, miscarriage, cardiac arrest.

     I understand that medications, drugs, and anesthetics may cause drowsiness and lack of coordination, which can be increased by the use of alcohol or other drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medications and/or drugs, or until fully recovered from their effects (this includes a period of at least twenty- our { 24 } hours after my release from surgery).

     I understand that occasionally, upon injection of a local anesthetic, I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection.

     I understand that if I select to utilize Nitrous Oxide, “Atarax”, Chloryl hydrate, “Zanax” , or any other sedative, possible risks include, but are not limited to, loss of consciousness, obstruction of airway, anaphylactic shock, cardiac arrest. I understand that someone needs to drive me home from the dental office after I have received sedation.

     I also understand that someone needs to watch me closely for a period of 8 to 10 hours, following my dental appointment, to observe for possible deleterious side effects, such as obstruction of airway.

     I understand that the long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e. brushing and flossing) and maintaining regular recall visits.

1. Post-operative discomfort; swelling; prolonged bleeding; tooth sensitivity to hot or cold; gum shrinkage (possibly exposing crown margins); tooth looseness; delayed healing (dry-socket) and/or infection (requiring prescriptions or additional treatment, i.e. surgery).
2. Injury to adjacent teeth, cusps, or filling (requiring the recementation of crowns, replacement of fillings, fabrication of crowns, or extraction), or injury to other tissues not within the described surgical area.
3. Limitation of opening; stiffness of facial and/or neck muscles; change in bite; or temporomandibular joint (jaw joint) difficulty (possibly requiring physical therapy or surgery).
4. Residual root fragments or bone spicules left when complete removal would require extensive surgery or needless surgical complications.
5. Possible bone fracture which may require wiring or surgical treatment.
6. Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
7. Injury to the nerve underlying the teeth resulting in itching, numbness, or burning of the lip, chin, gums cheek, teeth and/or tongue on the operated side; this may persist for several weeks, months, or, in remote instances, permanently.

     I give my consent for the doctor to perform the treatment/procedure/surgery previously explained to me, or other procedures deemed necessary or advisable as necessary to complete the planned operation.

     If any unforeseen condition should arise in the course of the operation, calling for the doctor’s judgement or for procedures in addition to or different from those now contemplated, I request and authorize the doctor to do whatever (s)he may deem advisable, including referral to another dentist or specialist. I also understand that the cost of this referral would be my responsibility.

     I have been advised of the need for fillings, either silver or composite (plastic), to replace tooth structure lost to decay. I under-stand that with time fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post and build up, and crowns), which would necessitate a separate charge.

     I understand that the silver amalgam restoration is an acceptable procedure according to the American Dental Association guidelines and, as such, is a treatment used by your dentist. The advantages and disadvantages of alternate materials have been explained to me.

1. Post treatment discomfort lasting a few hours to several days for which medication will be prescribed if deemed necessary by the doctor.
2. Post treatment swelling of the gum area in the vicinity of the treated tooth or facial swelling wither of which may persist for several days or longer.
3. Infection.
4. Restricted jaw opening.
5. Breakage of root canal instruments during treatment, which may in the judgment of the doctor be left in the treated root canal or bone as part of the filling material, or it may require surgery for removal.
6. Perforation of the root canal with instruments, which may require additional surgical treatment or result in premature tooth loss or extraction.
7. Risk of temporary or permanent numbness in treatment area.

If an “open and medicate” or pulpotomy procedure is performed, I understand that this is not permanent treatment, and I need to pay for, and finish final root canal therapy. If root canal treatment is not finalized I expose myself to infection and/or tooth loss.

     I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur, necessitating possible root canal therapy.

     I understand that like natural teeth, crowns and bridges need to be kept clean, with proper oral hygiene and periodic cleaning, otherwise decay may develop underneath and/or around the margins of the restoration, leading to further dental treatment.

     The problems of wearing dentures has been explained to me including looseness, soreness, and possible breakage, and relining due to tissue change. Follow-up appointments are an integral part of maintenance and success of a prosthetic appliance. Persistent sore spots should be immediately examined by the doctor.

     I further understand that surgical intervention (i.e. tori[bone] removal, bone recontouring, or implants) may be needed for dentures to be properly fitted. I also understand that due to bone loss or other complicating factors, I may never be able to wear dentures to my satisfaction.

1. POSITIVE REINFORCEMENT- Rewarding the child who portrays desirable behavior, by use of compliments, praise, a pat or hug, and/or token objects or toys.
2. VOICE CONTROL- The attention of a disruptive child is gained by changing the tone or increasing the volume of the doctors voice.
3. PHYSICAL RESTRAINT- Restraining the child’s disruptive movements by holding down their hands, upper body, head, and/or legs by use of the dentist’s or assistant’s hand or arm, or by use of a special device (referred to as a “papoose board”).
4. NITROUS OXIDE AND/OR ORAL SEDATION- Nitrous Oxide is a mild gas that is mixed with oxygen, and is used to sedate a person. It is administered through a mask placed over the child’s nose. Oral sedation are medications administered to children to help them relax. With their use the parent/or guardian must understand that the child should not eat or drink for a period of four hours prior to the sedation appointment. The parent/guardian must be available to escort the child home after the sedation procedure, and observe their behavior throughout the day.

     I understand that with the use of an injection, used to numb the tooth area for dental procedures, the possibility exists that the child may inadvertently bite their lip causing injury to occur.

     I understand the need to return to the office, for evaluation, if swelling and/or pain in my child does not go away after a sufficient period of time.

     I understand the need to return to the office within three months following nerve treatment of a “baby tooth” for evaluation, and the possibility of it the needing an extraction.

I UNDERSTAND THAT NO GUARANTEE OR ASSURANCE HAS BEEN GIVEN THAT THE PROPOSED TREATMENT WILL BE CURATIVE AND/OR SUCCESSFUL TO MY COMPLETE SATISFACTION. I AGREE TO COOPERATE COMPLETELY WITH THE COMMENDATIONS OF THE DOCTOR WHILE I AM UNDER HER/HIS CARE, REALIZING THAT ANY LACK OF SAME COULD RESULT IN LESS THAN OPTIMUM RESULTS.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE, INCLUDING THE OPPOSING SIDE OF THIS DOCUMENT, AND CONSENT TO THE OPERATION AND EXPLANATION REFERRED TO OR MADE. I HAVE BEEN ENCOUNTERED TO ASK QUESTIONS, AND HAVE HAD THEM ANSWERED TO MY SATISFACTION.

I UNDERSTAND THESE DENTAL SERVICES ARE PROVIDED WITHOUT DISCRIMINATION BASED ON RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION, PHYSICAL OR MENTAL DISABILITY, AGE OR MARITAL STATUS AND PROTECTS THE PRIVACY OF EACH OF IT’S PATIENTS.