Crown, Bridge, Inlay, Veneer Consent Form Logo

  • Crown, Bridge, Inlay, Veneer Consent Form

  • To: Robert Korwin DMD PA And Associates:

    This is my consent for Drs. Korwin and associates to perform the following crown, bridge, inlay, onlays, or veneer procedure, not including a post and core or a crown build-up or future procedures:

  • CROWNS, BRIDGES, INLAYS AND VENEERS are done to try to save teeth which would otherwise require extraction, or to change the size, color, and shape of teeth, or to replace missing teeth.

    There are alternatives to crowns, bridges, inlays, onlays and veneers.  These include waiting for more pronounced symptoms to develop, tooth extraction, temporary restorations, implants, bonding, or no treatment at all.

    The risks involved in these alternative choices may include discomfort, root canal infection, loss of teeth, and fractures of teeth.

    Post-treatment problems have a small chance of occurring, but if they do occur, might include one or more of the following risks:

    CROWNS, BRIDGES, INLAYS AND VENEERS are done to try to save teeth which would otherwise require extraction, or to change the size, color, and shape of teeth, or to replace missing teeth.

    There are alternatives to crowns, bridges, inlays, onlays and veneers.  These include waiting for more pronounced symptoms to develop, tooth extraction, temporary restorations, implants, bonding, or no treatment at all.

    The risks involved in these alternative choices may include discomfort, root canal infection, loss of teeth, and fractures of teeth.

    Post-treatment problems have a small chance of occurring, but if they do occur, might include one or more of the following risks:

  • READ AND DISCUSS EACH ITEM BELOW.  INITIAL EACH LINE ONLY AFTER YOU UNDERSTAND EACH

  • 1. Post-operative infection or sensitivity requiring additional treatment including root canals, surgery, or extraction. This may be done at this office or by a specialist. The fee for any additional treatment is not included in the current treatment.

  • Clear

  • 2. Stretching of the corners of the mouth with resulting cracking or bruising. Possible restricted mouth opening for several days or weeks from opening wide during treatment.

  • Clear

  • 3. Crowns, bridges, inlays onlays or veneers cannot be successful with every tooth. I understand further treatment may be necessary and an additional fee may be charged for retreatment, root canal, surgery, or extraction.

  • Clear

  • 4. Treatment complications may be discovered which alter the original treatment plan or may require changed treatment. These complications may include fractured teeth, gum problems, bone problems, root infections, difficult color blends, and difficulty in home care maintenance.

  • Clear

  • 5. If endodontic treatment is required within a year of crown placement, the crown will be replaced as a courtesy. If endodontic treatment is required after a year of crown placement, the patient is responsible for the crown replacement fee.

  • Clear

  • 6. Some insurance companies will not cover crowns for fractured teeth until they are completely broken, however the patient is still responsible for the fee if treated.

  • Clear

  • 7. Since it may interfere with treatment, I agree to turn off my cell phone until the procedure is complete.

  • Clear

  • 8. Please bring your night guard or retainer to each visit. It may be necessary to remake a night guard or retainer for an additional fee if satisfactory adjustments to the appliance cannot be made.

  • Clear

  • 9. For all veneer procedures you will be required to have a cleaning 3 to 5 days prior to the insert of the veneer.

  • Clear

  • 10. I understand that after my crown/bridge/onlay/veneer has been cemented, should I choose to change the color, there will be an additional charge.

  • Clear

  • 11. I understand that after my crown/bridge/onlay/veneer, retainers may need to be remade after new dental treatment has been completed for an additional fee.

  • Clear

  • I have had an opportunity to discuss my past medical and health history, including any serious prior problems. I have asked questions about the procedure and its alternatives. I fully understand the terms and words within the above consent to the procedure, and the explanation of each item, which I have initialed. Despite my being informed of these risks, and being offered additional time for consideration, I request that the procedure be performed now.

  • Clear
  • Clear
  • Clear
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