Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Reduction of the tooth structure: In order to replace decayed or otherwise traumatized teeth, it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as practical. In the preparation of teeth, anaesthetics are usually needed. At times there may be swelling, jaw muscle tenderness or even a resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues which is usually temporary, or very rarely, permanent. *

I understand

Sensitivity of teeth: Often, after the preparation of teeth or the reception of either crowns or bridges, the teeth may exhibit sensitivity. It may be mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If it is persistent, notify us inasmuch as this sensitivity may be from some other source. *

I understand

Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.

I understand

Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminate periods of time following placement of the prosthesis. *

I understand

Aesthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in place prior to final cementation *

I understand

Longevity of crowns and bridges: There are many variables that determine “how long” crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. Additionally, general health, good oral hygiene, regular dental check-ups , diet, etc. , can affect longevity. Because of this, no guarantees can be made or assumed to be made. I, the undersigned, understand that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGE WORK includes certain risks and possible unsuccessful results, with even the possibility of failure. I agree to assume those risks, possible unsuccessful results and/or failure associated with, but not limited to the following: (even though care and diligence are exercised in the treatment of conditions requiring crowns and bridgework and fabrication of same, there are no promises or guarantees of anticipated results or the longevity of the treatment).

I understand

In case of Emergency: It is a patient’s responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow any and all instructions, including the scheduling and attending all appointments. Failure to keep the cementation appointment can result in ultimate failure of the crown/bridge to fit properly and an additional fee may be assessed. *

I understand

Informed consent *

I have been given the opportunity to ask any questions regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction. I voluntarily assume any and all possibly risks including those as listed above and including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results. The fee(s) for service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize my Doctor to render any treatment necessary and/or advisable to my dental conditions including the prescribing and administering of any medications and/or anaesthetics deemed necessary to my treatment.

I Consent

Date *

MM

DD

YYYY