NIGHT GUARD CONSENT FORM

CONSENT TO Dr. Robert Korwin, his Associates and Staff performing on me the outlined Night Guard. I realize this procedure is elective in nature.

My night guard will require repair or replacement over time due to use and change in shape of my mouth over time. These repairs or replacements are not included in the original fee for the night guard.

I accept and understand that some of the side effects of the outlined treatment plan may include, but are not exclusive of, looseness of night guard, and inherent change in fit over time.

I understand and accept that, as with any medical or dental procedure, there are no guarantees as to the longevity of the work performed. As always, I, the patient, play a major role in maintaining my teeth and restorations. This does not warranty against loss of teeth due to disease. I agree to maintain good oral hygiene and keep regular dental check-ups and cleaning appointments with Dr. Korwin at least every 3 to 6 months as recommended by Dr. Korwin. I also agree to wear my night guard every night as instructed if prescribed.

I understand and give consent that photographs may be taken of the procedures, as well as before and after photographs. These photographs will be used for documentation, diagnosis, treatment planning and may be used for presentation and marketing purposes.

INSTRUCTIONS FOR YOUR NIGHT GUARD USE

1. When you start using your new appliance, it will feel bulky and foreign. Your mouth will also salivate. After 2 weeks to one month of continuous use, you will feel natural and you will salivate little or not at all. Most people feel that they cannot sleep without the night guard after continuous use.

2. Please use Kleenite to clean the appliance. Disregard the line that says use hot tap water, use warm tap water. Hot tap water will distort the material. Do not use Listerine or other mouthwashes, as the acrylic will harden and no longer fit well. Remove from your mouth in the morning and brush and rinse the appliance with water.

3. Air dry the appliance after use, then keep it in its case dry for storage or transportation

4. Keep the night guard away from pets as they love them as chew toys.

5. If the night guard no longer fits or, your teeth feel uncomfortable after use, please call for an appointment to adjust the appliance.

6. Wear spots in the night guard are normal; your teeth would have worn instead. Cracks can be harmful since the appliance may separate in your mouth. Please discontinue use if the appliance is fractured, and have a new one made.

When you have any questions please call and our staff will be happy to help you.