Patient_______________________
General Dentistry Informed Consent
1. DRUGS AND MEDICATION:
I understand that antibiotics, analgesics and other medications can cause adverse reactions: redness and swelling of
tissues, pain, itching vomiting, miscarriage and possible death. I have been advised not to operate any vehicle or
hazardous device while taking medications or until fully recovered from their effects. BENEFITS: Reduce pain, swelling,
fever and infections. CONSEQUENCES if medications are not taken: pain, swelling, fever, infection and tooth loss.
INITIALS_________
2. LOCAL ANESTHETICS:
Possible complications: I understand local anesthetics can cause prolonged persistent anesthesia, numbness and or
irritation to injection site. BENEFITS: Avoidance of pain during treatment and procedures. CONSEQUENCES: May cause
allergic reaction and/or fainting. if not used: Mild to severe pain during and after treatments. INITIALS__________
3. X-RAYS:
Possible complications: I understand that exposure to x-ray radiation is minimal. BENEFITS: A more complete diagnosis is
available. CONSEQUENCES: Incomplete diagnosis and treatment plan. INITIALS__________ NOTE: If you are pregnant or
think that you might be, PLEASE let us know before any x-rays are taken, INITIALS__________
4. CHANGES IN TREATMENT PLAN:
I understand that during treatment, it may become necessary to change or add procedures, because of conditions found
while working on the teeth that were unseen during the examination. For example: Root canal therapy following routine
restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.
INITIALS__________
5. EXTRACTION OF TEETH:
I authorize the Dentist to remove the following teeth_______________. POSSIBLE COMPLICATIONS: I have been advised that
if my condition persists without treatment; my present oral condition will only worsen with time. Potential risks of oral
surgery include, but are not limited to: Post operative discomfort, swelling, dry socket, infection and possible injury to
adjacent teeth, crowns or fillings. There might be a residual bone spicule or root fragment left when complete removal
would require extensive surgery and needless complication. I understand that after an extraction, there may be stiffness of
facial and neck muscles, a change in bite or possible TMJ joint difficulties. I also understand that bad infections take a
while to clear up. BENEFITS: Helps to eliminate pain and infection. CONSEQUENCES: A general worsening of my present
oral condition, continued spread of the infection, swelling and pain. In rare instances, death can result. ALTERNATIVES:
Possible Endodontic or periodontic therapy. INITIALS__________
6. CROWNS, BRIDGES, VENEERS, ONLAYS AND INLAYS:
POSSIBLE COMPLICATIONS: I understand that breakage can occur with any porcelain product, resulting in a remake.
Once placed, these treatments can be extremely difficult to remove. If the porcelain fractures on a crown or bridge, they
will need to be repaired and recemented. A tooth under any of the above procedures may abscess requiring a Root Canal.
New decay at the edges of the crown is possible if I do not maintain my oral hygiene. I understand that sometimes it is not
possible to match the color of natural teeth exactly with man made porcelain product. BENEFITS: improves appearances,
can close gaps or spaces between teeth and protects weakened tooth structure. CONSEQUENCES: Tooth may fracture.
ALTERNATIVES: Crowns or Partial Removable Dentures. INITIAL__________
7. ENDODONTIC TREATMENT (ROOT CANAL):
POSSIBLE COMPLICATIONS: the purpose of the Root Canal Therapy has been explained to me, as well as alternatives
treatments. I have been informed that following the treatment my tooth will become dry and brittle and must be protected
against fracture by a crown. I have been made aware that an undiagnosable root fracture or an auxiliary canal means
failure and extraction. Post treatment swelling may be around for several days after treatment. Infection can continue.
Breakage of a Root Canal instrument which may or may not be left in the canal, (per the Doctor’s judgment), may require
additional oral surgery to retrieve.
continue on the back
Patient_______________________
Continued…..
Perforation of the canal may require additional surgical treatment or may result in the loss of the tooth.
BENEFITS: Eliminates decay, relieves pain and saves the tooth. CONSEQUENCES: Continued infection, pain and loss of
tooth. ALTERNATIVES: Extraction. INITIALS__________ NOTE: if an open and medicate is done on a tooth, I understand
that this is NOT a permanent treatment INITIALS__________
8. PERIODONTAL, CLEANING, SCALING AND HYGIENE:
POSSIBLE COMPLICATIONS: some teeth may be sensitive. If a periodontal condition, this is a serious condition causing
gum inflammation, leading to bone loss. This bone loss can lead to the loss of my teeth and other physical problems.
Sometimes the teeth treated will still require extraction. BENEFITS: stains are removed from teeth; heavy calculus is
removed, eliminates infection, helps arrest bone loss and may help tighten teeth that have some mobility.
CONSEQUENCES: Unhealthy teeth and gums leading to tooth loss. ALTERNATIVES: None. INITIALS__________
NOTE: I understand that the long term success of the periodontal treatment depends on my oral home care. INITIALS_____
9. FILLING:
POSSIBLE COMPLICATIONS: I understand the need for fillings, either amalgam or composite, to replace tooth structure
lost through decay. I realize that in time, fillings need to be replaced due to the wear on the material. If the decay is very
deep, the tooth may become abscessed after the filling is completed. I understand that the toxicity from amalgam fillings
has been alleged, but is an acceptable procedure according to the ADA guideline. The advantages and disadvantages of the
alternate materials have been explained to me. BENEFITS: Eliminates decay, relieves pain and protects a sensitive surface.
CONSEQUENCES: Root Canal Therapy and a crown, or an extraction. ALTERNATIVES: Tooth Loss. INITIALS: __________
10. DENTURES, PARTIAL OR FULL:
POSSIBLE COMPLICATIONS: Looseness, soreness, possible breakage and relining due to tissue shrinkage. There are
follow-up appointments for maintenance. Partial clasps can wear out the natural teeth, can rock or cause stress to my own
teeth. The metal clasps are sometimes visible and decay can occur under the clasps if I do not maintain my oral hygiene.
There is always some movement under a denture. BENEFITS: Less cost. CONSEQUENCES: Existing teeth move, food is not
properly chewed and health problems may develop. ALTERNATIVES: Crown and bridges. INITIALS__________
11. WORK TO BE DONE:
I understand that I am having the following work done: INITIALS INDICATED
( ) X-rays/Oral exam________ ( ) Fillings________ ( ) Crown/Bridges________ ( ) Root Canals________ ( ) Extractions________
( ) Dentures________ ( ) Other____________________________________________________________________________________________________ .
I HAVE READ THE ABOVE STATEMENTS AND A COPY IS AVAILABLE TO ME UPON REQUEST. MY INITIALS INDICATE THAT I HAVE
READ AND UNDERSTAND THIS CONCENT DOCUMENT. I UNDERSTAND THERE IS NO ABSOLUTE GUARANTEE OR ASSURANCE CAN BE
GIVEN WITH THE PROPOSED TREATMENT. I ALSO UNDERSTAND THAT MY COOPERATION WITH THE RECOMMENDATIONS AND
REQUESTS BY THE DENTIST IS VERY IMPORTANT. THE LACK OF SAME WILL RESULT IN LESS THAT OPTIMUM RESULTS AND
SATISFACTION. IF FOR ANY REASON A CONFLICT ARISES, I WILL FIRST PRESENT SUCH CONFLICT OR DISAGREEMENT TO THE
DENTIST, IN ORDER TO RESOLVE THE PROBLEM
I NOW GIVE MY CONSENT, TO THE DENTIST, TO RENDER TO ME THE DENTAL TREATMENT THAT WE HAVE COLLECTIVELY AGREED
UPON AS NECESSARY FOR MY ORAL HEALTH AND WELL BEING. I FURTHER AGREE TO REIMBURSE THE DENTIST FOR ALL SERVICES
RENDERED TO ME. I AM AWARE THAT FULL PAYMENT OR MY SHARE OF COST, FOR THESE SERVICES IS DUE AT THE TIME THEY ARE
RENDERED.
Signature of patient or guardian: _________________________________________________________________Date:_____________________________
Signature of Doctor: _______________________________________________________________________________Date:_____________________________