Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Occasionally, medication will be prescribed by Dr R Badeli. Medications prescribed for discomfort and/or sedation may cause drowsiness, which can be increased by the use of alcohol or other drugs. We advise that you do not operate a motor vehicle or any hazardous device while taking such medications. In addition, certain medications may cause allergic reactions, such as hives or intestinal discomfort. If any of these problems occur, call Dr R Badeli. immediately. It is the patient's responsibility to report any changes in his/her medical history to Dr R Badeli. *

I understand

I understand that root canal therapy is a procedure that retains a tooth, which may otherwise require extraction. Although root canal therapy has a very high degree of success, results cannot be guaranteed. Occasionally, a tooth, which has had root canal therapy, may require retreatment, surgery, or even extraction. *

I understand

Following treatment, the tooth may be brittle and subject to fracture. A restoration (filling), crown and/or post and core will be necessary to restore the tooth, and your dentist will perform these procedures.

I understand

During endodontic treatment, there is the possibility of instrument separation within the root canals, perforations (extra openings), damage to bridges, existing fillings, crowns or porcelain veneers, missed canals, loss of tooth structure in gaining access to canals, and fractured teeth. Also, there are times when a minor surgical procedure may be indicated or when the tooth may not be amenable to endodontic treatment at all. *

I understand

During endodontic treatment, there is the possibility of instrument separation within the root canals, perforations (extra openings), damage to bridges, existing fillings, crowns or porcelain veneers, missed canals, loss of tooth structure in gaining access to canals, and fractured teeth. Also, there are times when a minor surgical procedure may be indicated or when the tooth may not be amenable to endodontic treatment at all. *

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

IMPORTANT: All of my questions have been answered by Dr R Badeli, and I fully understand the above statements in this consent form.

If you have any concerns please call us to speak to Dr Badeli about the treatment

I understand