To Our Valued Patient

Under the law in New Jersey, a dentist is obligated to inform a patient of dentally acceptable treatment alternatives and their attendant probable risks and outcomes, and the costs relative to the treatment that is recommended and/or rendered, so a patient can make a decision that is informed. Most procedures are discussed below, not all of which may pertain to your needs right now, since the Dentist may recommend further treatments at future examinations. This form, together with our conversation about treatment alternatives, risks and outcomes, is intended to fulfill Dentist’s legal obligation to obtain informed consent. Please read all items below.

1. Changes in Treatment Plan. During the course of treatment, procedures may need to be added, expanded or changed because conditions are found that were not first identified during examination and were observed during the course of treatment. The most common include the need for root canal therapy and more extensive restorative procedures, like crowns, bridges or implants. Further, in the Dentist’s discretion, I may be referred to a specialist for further treatment, the cost of which is my responsibility.

2. Drugs, Medications and Sedation. Drugs, medications or anesthesia/sedation can cause allergic and other reactions, such as: swelling, redness, itching, vomiting, diarrhea, numbness or tingling of the lip, gum or tongue (which in rare cases may be permanent) and also in rare cases, anaphylactic shock. For women, antibiotics can reduce the effectiveness of birth control pills.

3. Fillings. The most common conditions encountered with fillings are pain, sensitivity to temperature or pressure, fractures of teeth or roots, nerve damage, damage to other teeth, occlusal (bite) discrepancies, temporomandibular joint problems and occasional allergic reactions to filling materials.

4. Endodontic Treatment (Root Canal). I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment. Occasionally, one of the delicate instruments used to perform a root canal may break in the tooth. A failed root canal may require re-treatment, surgery or extraction. Once a tooth has received root canal treatment, it tends to be more brittle and restoration with a crown is recommended.

5. Crowns, Onlays/Inlays, Bridges, Veneers and Bonding. Sometimes, it is difficult or impossible to exactly match the color of artificial teeth or restorative materials with natural teeth. Although assistance will be provided by the Dentist, it is my responsibility to make changes, if any, (including, for example, shape, size, fit and color) before permanent cementation. After a temporary crown has been placed, it is essential to have the new crown cemented as soon as it is ready. Other possible conditions are similar to those listed under “fillings”.

6. Dentures. I realize that dentures are artificial. The problems of wearing these appliances will be explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new denture will be the “teeth in wax” try-in visit. Immediate dentures are considered transitional, and a new set of dentures and/or relining of the denture may be required after healing and shrinkage is complete, at an additional charge.

7. Extractions. Alternatives to removal, as well as replacement options, have been explained. Possible complications include: bleeding, swelling, bruising, pain, infection, dry socket, damage to adjacent teeth or restorations, opening to the sinus, incomplete removal of tooth fragments, fracture of the bone or bone splinters, temporary or permanent numbness.
CONSENT: I have read and understand all the above information. The undersigned hereby authorizes the Doctor to perform those diagnostic and treatment procedures deemed necessary. I understand that dentistry is not an exact science; therefore reputable practitioners cannot guarantee results. In addition, all procedures have inherent risks associated with them. I understand that another dentist may treat me in this office, and that he/she is individually responsible for the dental care rendered to me. If I ever have any change in my health or change in my medication, I will inform the Doctor at the next appointment. I have discussed/will discuss treatment alternatives, risks, outcomes and costs with the Dentist and have had/ will have all of my questions answered before making a decision.

(This form will be signed using an electronic signing pad when you arrive at the office.)