Las Vegas Smile Center
Patient Name__________________________________
Date of birth: ____________________________
1. DRUGS AND MEDICATIONS:
(Initials________)
I understand that analgesics and other medications can cause allergic reactions causing redness, swelling of tissue, pain, itching, vomiting,
and/or anaphylactic shock (severe allergic reaction).
2. HYGIENE AND PERIODONTAL DISEASE (TISSUE AND BONE LOSS):
(Initials________)
I understand that the long term success of treatment and status of my oral condition depend on my effort at proper oral hygiene (i.e. brushing
and flossing) and maintaining recall visits. I also understand that not undertaking periodontal treatment may have an adverse effect on my
periodontal condition and can lead to more extensive periodontal treatment and possible loss of some or all of my teeth.
3. ENDODONTIC TREATMENT (ROOT CANAL):
(Initials________)
I understand that root canal therapy is performed in an effort to save my tooth. I understand the reason for root canal treatment is to remove
decay that has extended into the pulp chamber where the nerve is situated. I realize that if left untreated, the infection in the nerve can travel
down to the bone and cause swelling and abscess and eventually to loss of the tooth.
4. CROWNS, BRIDGES, AND VENEERS:
(Initials________)
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand I may be
wearing temporary crowns, which may come off easily, and I must be careful to ensure that they are kept on until the final crown restorations
are delivered. I realize the final opportunity to make changes in my new crown, bridge, or veneers (including shape, fit, size and color) will be
before cementation. I understand if I do not return for my scheduled appointment for the delivery of my crown, bridge, or veneer, it may not
fit properly, and I will be responsible for all fees incurred if a remake becomes necessary.
5. REMOVAL OF TEETH:
(Initials________)
I understand removing teeth is not the best option unless there are no other alternatives that can save the tooth. I understand the risks
involved in having my 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. I understand that I may need further treatment by a
specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.
6. DENTURES-COMPLETE OR PARTIAL:
(Initials________)
I realize full or partial dentures are artificial, constructed of acrylic, nylon, plastic, metal and /or porcelain. The problems of wearing these
appliances may vary and include soreness, looseness, and possibility of breakage. I realize the final opportunity to make changes in my new
denture (including shape, fit, size, placement and color) will be at the try-in with wax visit. I understand most dentures require relining
approximately three to six months after initial placement and yearly thereafter. The cost of these relines is not included in the denture fee.
7. IMPLANTS:
(Initials________)
I understand that implants are the first choice of treatment given by Dr. Arian to replace my missing teeth. Implants can replace one tooth or
several missing teeth or they can act as an anchor for fixed/removable appliance to make them more stable and retentive. I understand that in
some instances implants fail and must be removed and there is no method to accurately predict the gum and the bone healing capabilities in
each patient following the placement of the implant.
8. SEALANTS:
(initials________)
Sealants are usually performed on teeth with deep fissures and groves to create a smooth surface to prevent food and/or plague entrapment
into those tooth surfaces which may lead to decay. Depending on the oral hygiene, sealants may dissolve or break away from the tooth causing
possible decay.
9. SPACE MAINTAINERS:
(Initials________)
I understand that a space maintainer is a fixed appliance. I further understand that I am fully responsible to have the appliance checked every
month by Dr. Arian. Failure to keep my appointments may result in tooth decay and/or periodontal disease which may result in tooth loss.
10.FILLING / BONDING:
(Initial_________)
I understand that sensitivity is common after effect of a newly placed filling. I understand that a more extensive filling than originally diagnosed
may be required due to additional decay. I further understand that care must be exercised on fillings especially during the first 24 hours and
more adjustments may be needed if the filling is in premature occlusion.
11.CHANGES IN TREATMENT PLAN:
(Initials________)
I understand that during treatment, it may be necessary to change or add procedures due to conditions found while working on the teeth that
were not discovered during examination. The most common being root canal therapy following routine restorative procedures.
I understand that dentistry is not an exact science and that therefore practitioners can not guarantee results. I acknowledge that no guarantee
or assurance has been made by anyone regarding my dental treatment.
Signature of patient, Parent, or guardian:___________________________________________ Date:__________________________