General Dentistry Informed Consent

1. Treatment Plan

I fully understand the recommended treatment, and my financial responsibility as explained to me. I fully understand that by signing this form, I am in no way obligated to any treatment. I also acknowledge 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. Example: Root canal therapy following routine restorative procedures.

2. Drugs, and Medications

I fully understand that antibiotics, analgesics, and other medications can cause allergic reactions such as redness, swelling tissue, pain, itching, vomiting, and / or anaphylactic shock.

3. Tooth Extraction

Alternatives to removal of teeth have been explained to me (root canal therapy, crown, and bridge procedures, periodontal therapy, and etc.). I fully understand removing teeth does not always remove infection, if present, and may be necessary to have further treatment. I fully understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue, and surrounding tissue (paresthesia) that can last for an indefinite period of time, or fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility.

4. Crowns’, Bridges, and Veneers

I fully understand that sometimes it is not possible to match the color of natural teeth exactly with an artificial teeth. I further understand that I may be wearing temporary crowns which comes off easily, and that I must be careful to ensure that they are kept on until the permanent crown is delivered. I realize the final opportunity to make changes (shape of, fit, size, and color) will be before cementation. It is also my responsibility to return for permanent cementation within twenty (20) days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown or bridge. I understand that there will be additional charges for remakes due to the delayed permanent cementation.

5. Endodontic Therapy

I understand there is no guarantee that a root canal will save m tooth, and that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files, and reamers are very fine dental instruments, and stresses, and defects in their manufacturing can cause them to separate during use. I fully understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicectomy). I fully understand that the tooth may be lost in spite of all efforts to restore it.

6. Periodontal Disease

I fully understand that I have been diagnosed with a serious condition, causing gum, and bone inflammation, and / or loss that the result could lead to the loss of teeth. Alternative treatments have been explained to me, including gum surgery, tooth extraction, and / or replacement.

7. Fillings

I fully understand that care must be exercised in chewing on filling teeth, especially during the first twenty four (24) hours to avoid breakage. I fully understand that a more extensive restorative procedure than originally diagnosed may be required due to additional or extensive decays. I fully understand that significant sensitivity is a common after effect of newly placed fillings.

8. Partials, and Dentures

I fully understand the wearing of partials / dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of dentures immediately after extractions) may be painful. Immediate dentures may require considerable adjusting, and several relines. A permanent reline will be needed at a later date, and this is not included in the denture fee. I fully understand that it is my responsibility to return for delivery of my partial denture. I fully understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than thirty (30) days, additional charges will be applied.


I fully understand that dentistry is not an exact science, and that, therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested, & authorized.