INFORMED CONSENT FOR DENTAL TREATMENT

Please read and initial the following
You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Preliminary Consent for Treatment
I understand I am having any or all of the following done today: Exam, Radiographs “X-rays” and Cleaning “Prophylaxis”

Medications, Substances, and Medical Conditions
I understand that antibiotics, analgesics “Pain medicines”, anesthetics, Latex, and other substances can cause allergic reactions, resulting in redness and swelling of tissues, itching, pain, vomiting and/or more severe allergic reaction. I have informed the dentist of any known allergies and/or medical conditions, including possible pregnancy.

Changes In Treatment Plan
I understand that during treatment it may be necessary to change or add procedures because of conditions found during treatment that were not evident during the initial examination. Some of these changes are, but are not limited to, root canal therapy that is necessary following the placement of “deep fillings” or crowns recommended after placement of “Large Fillings” or fillings turning more surface than anticipated. I authorize my treatment plan as necessary.

I understand dental treatment has potential risks and consequences. Likewise, so does the refusal or denial of dental treatment. Untreated conditions may lead to pain, swelling, infection, tooth loss and/or other severe consequences. I understand that dentistry is not an exact science and that no exact results can be assured or guaranteed. I have had the opportunity to have all of my questions answered by my dentist.

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.