For your convenience, we make available this generalized dental consent form for your review and signature. Please do not hesitate to ask your dental staff any questions you may have. For more information, please visit our website www.derrydental.com
In understand there are risks of local anaesthesia that may affect m y body such as dizziness, nausea, vomiting, accelerated heart rate, or various types of allergic reactions. It may also cause injury to nerves that can result in pain, numbness, tingling that may persist for several weeks, months, or rarely, be permanent. I have informed my doctor of my complete medical history including any recent surgeries or changes in my medical history. I understand that antibiotics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe) allergic reactions).
I understand that during treatment it may be necessary to change or add procedures because of 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 the most common complications are pain, sensitivity to temperature, fracture of tooth, nerve damage, damage to other teeth, occlusal (bite) discrepancies, TMJ complications, reactions to drugs and/or anaesthesia.
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size, and color) will be before cementation.
If the teeth are salvageable/restorable, the alternatives to removal of teeth are root canal therapy, crowns, and periodontal surgery, etc. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread or infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand 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.
I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances include looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.
I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).
I understand that most common complications are pain, bleeding, tissue (gum) laceration, sensitivity to temperature or foods, swelling ulceration (infection), tooth fracture, breaking of fillings. Reactions to fluoride treatment may be nausea or vomiting.
You may also understand the risk of any pandemic spread that we have no control over, it’s mandatory to report any current positive result of such virus/infection. You understand virus can spread through travelling through public transport, by going to any outside facility and it’s your responsibility to take precautions as required.
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for myself or my minor child. I had had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction.
Thank you for entrusting your dental treatment to Derry Village Dental Care. It is an honor for us to have been selected by you to do so. Our service philosophy is to be informed, honest, and fair. This Financial Agreement demonstrates our appreciation for your right to know ahead of time what our financial expectations are. Please contact our office of you have any questions or issues regarding our Financial Agreement.
We will happily submit your claims and accept assignment of dental insurance coverage as a favor if you agree to the following: