CONSENT FOR FILLINGSc1-preview.prosites.com/50781/wy/docs/Consent Forms 2.pdfThere is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial

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Patient Name:

CONSENT FOR FILLINGS

Date:

Diagnosis,{Recommended Treatment :

I understand that the treatment of my dentition involving the placement of SILVER AMALGAMFILLINGS OR COMPOSITE RESIN FILLINGS may entail ceftain risks. There is the possibility offailure to achieve the desired or expected results. I agree to assume those risks that may occur, even ifcare and diligence is exercised by rry treating dentist in rendering this treatment. These risks includepossible unsuccessful results and /or failure of the filling associated with, but not limited to the following:

1. Sensitivity of teethOften after preparation of teeth for the placement of any restoration, the prepared teeth may exhibitsensitivity. The sensitivity can be mild or severe. The sensitivity can last only for a short period oftime or last for much longer periods of time. If such sensitivity is persistent or lasts for an extendedperiod of time, I will notify the dentist because this can be a sign of more serious problems.

2. Risk of fractureInherent in the placement or replacement of any restoration, is the possibility of the creation of smallfracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removalof the tooth structure andlor the previous fillings and placement or replacement, but they can appear at

a later time.

3. Necessity for root canal therapyIf the tooth has a deep area of decay that is close to the nerve a root canal may be required.When fillings are placed or replaced, the preparation of the teeth often requires the removal of toothstructures adequate to ensure that the diseased or otherwise compromised tooth structure providessound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma tounderlying pulp tissue. Should the pulp not heal, which often is exhibited by extreme sensitivity orpossible access, root canal treatment or extraction may be required.

4. Injury to nervesThere is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial tissuesfrom any dental treatment, particularly those involving the administration of local anesthetics. Theresulting numbness that can occur is usually temporary, but in rare instances it could be permanent.

5. Aesthetics or appearanceWhen a composite filling is placed, effort will be made to closely approximate the appearance ofnatural tooth color. However, because many factors affect the shades of teeth, it may not be possible toexactly match the tooth coloration. Also, the shade of composite fillings can change over time becauseof a variety of factors including mouth fluids, foods, smoking, etc. The dentist has no control overthese factors.

6. Breakage, dislodgement or bond failureBecause of extreme masticatory (chewing) pressures or other traumatic forces, it is possible forcomposite resin fillings or aesthetic restorations bonded with composite resins, to be dislodged orfractured. The resin-enamel bond can fail, resulting in leakage and recurrent decay. The dentist has

no control over these factors.

7. Fragility of silver amalgamSilver amalgam is quite fragile until it has completely solidified. It is necessary to avoid chewing onon recently placed amalgam fillings for approximately 24 hours.

8. Amalgam tattoosOccasionally shavings generated by placement or carving of silver amalgam fillings may work theirway into the surrounding gum tissues and become lodged. Over an extended period of time gray spotsor tattoos may become visible with the mouth.

9. New technology and health issuesComposite resin technology continues to advance, but some materials yield disappointing results overtime and some fillings may have to be replaced by better, improved materials. Some patients believethat having metal fillings replaced with composite fillings will improve their general health. Thisnotion has not been proven scientifically and there are no promises or guarantees that the removal ofsilver fillings and the subsequent replacement with composite fillings will improve, alleviate or preventany current or future health conditions.

Benefits:1. Removal of disease state, decay.2. Restoration of form and function in the oral cavitv.3. Prevention of pain and infection.

Informed ConsentI understand that it is my responsibility to notify this office should any undue or unexpected problemsoccur or if I experience any problems relating to the treatment rendered or the services performed. I havebeen given the opporlunity to ask any questions regarding the nature and purpose of the materials that willbe used and have received answers to my satisfaction. I voluntarily accept any and all possible risks,including the risk of substantial harm, if any that may be associated with any phase of this treatment inhopes of obtaining the desired outcome. By signing this document, I authorizeDr. James N. Angelosand/or his associates to render any services deemed necessary or advisable in the treatment of my dentalcondition, including the prescribing and administration of any medically necessary anesthetics and/orrnedications.

Please intial

_ I give my consent for the proposed treatment as described above.

_ I refuse to give my consent for the proposed treatment as described above.

_ I have been informed of the potential consequences of my decision to refuse treatment.

Patient's or Legal Guardian's Signature Date

Witness to Signature Dentist Signature Date

INFORMED CONSENT FOR LOCAL ANESTHETIC

Patient Name:

Treatment:

Date:

Anesthetizing agents (medications) are injected into a small area with the intent of numbing the area toreceived dental treatment. They also can be injected near a nerve to act as a nerve block causing numbness toa larger area of the mouth beyond just the site of injection.

Risks include but are not limited to.' It is normal for the numbness to take time to wear off after treatment,usually two to three hours. This can vary depending on the type of medication used. However, in some cases,

it can take longer, and in some rare cases, the numbness can be permanent if the nerve is injured.Infection, swelling, allergic reactions, discoloration, headache, tenderness at the needle site, dizziness,nausea, vomiting, and cheek, tongue, or lip biting can occur.

Potential benefits: The patient remains awake and can respond to directions and questions. Pain is lessenedor eliminated during the dental treatment.

For All Female Patients: Because anesthetics, medications and drugs may be harmful to the unbom childand may cause birth defects or spontaneous abortion, every female must inform the provider of anesthesia ifshe could be or is pregnant. Anesthetics, medications and drugs may affect the behavior of a nursing baby. lneither of these situations, the anesthesia and treatment may be postponed.

_ I have been given the opportunity to ask questions about the recommended method of anesthesia andbelieve that I have sufficient information to give my consent as noted below.

_I hereby give my consent for the use of local anesthetic, as explained above when Dr. James N. Angelosdetermines it is indicated in the treatment of Patient's Name).

OR

_ I refuse to give my consent for the proposed treatment (s) as described above and understand thepotential consequences associated with this refusal.

Patient or Patient's Representative Signature Date

I attest that I have discussed the risks, benefits, consequences, and alternatives of anesthesia with the abovename mentioned and/or their representative and they have had the opportunity to ask questions, and I believethey understand what has been explained and consents or refuses of treatment as noted above.

Dentist's Signature Date

Witness Signature Date

INFORMED CONSENT DISCUSSION FOR CROWNS

Patient name: Date:

Diagnosis:

Facts for Consideration

1. Treatment involves restoring damaged areas of the tooth above and below the gumline with a crown.

2. At times, due to the extent of the decay or if there is a crack or fracture present that is close to the nerveof the tooth a root canal may be required in addition to the crown.

3 . Restoration of a tooth with a crown requires two phases: 1 ) preparation of the tooth which involves reshapingthe tooth to a smaller size to fit the crown over it, an impression sent to the lab, shade check, construction andtemporary cementation of a temporary crown; and later, 2) removal of the temporary crown, adjustment, andcementation of the permanent crown after esthetics and function have been verified and accepted.

4. Once a temporary crown has been placed, it is essential to return to have the permanent crown placed as

the temporary crown is not intended to function as well as the permanent crown. Failing to replace thetemporary crown with the permanent crown could lead to decay, gum disease, infections, problems withyour bite, and loss of the tooth.

5. Permanent crowns can be made from different types of materials such as stainless steel, all metal (such as

gold or another alloy), porcelain fused to metal, all resin, or all ceramic. A thin metal margin may be presentat the gumline on some porcelain fused to metal crowns.

Benefits of Crowns, Not Limited to the Following:

A crown is typically used to strengthen a tooth darnaged by decay, fracture, or previous restorations. Itcan also serve to protect a tooth that has had root canal treatment and improve the way your other teeth fittogether. Crowns are used for the purpose of improving the appearance of damaged, discolored,misshapen, malaligned, or poorly spaced teeth.

Risks of Crowns, Not Limited to the Following:

1. I understand that preparing a damaged tooth for a crown may further irritate the nerve tissue (calledthe pulp) in the center of the tooth, leaving my tooth feeling sensitive to heat, cold, or pressure. Suchsensitive teeth may require additional treatment including endodontic or root canal treatment.

2. I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiffand sore and may make it difficult for me to open wide for several days. This can occasionally be anindication of a further problem. I must notify your office if this or other concerns arise.

3. I understand that a crown may alter the way my teeth fit together and make my jaw joint feel sore.This may require adjusting my bite by altering the biting surface of the crown or adjacent teeth.

4. I understand that the edge of a crown is usually near the gumline, which is in an area prone to gumirritation, infection, or decay. Proper brushing and flossing at home, a healthy diet, and regularprofessional cleanings are some preventative measures essential to helping control these problems.

5" I understand there is a risk of aspirating or swallowing the crown during treatment.

6. I understand that I may receive a local anesthetic and/or other medication. In rare instances patientsmay have a reaction to the anesthetic, which could require emergency medical attention, or find that itreduces their ability to control swallowing. This increases the normal chance of swallowing foreignobjects during treatment. Depending on the anesthesia and medications administered, I may need a

designated driver to take me home. Rarely, temporary or pennanent nenve injury can result from aninjection.

7. I understand that all medications have the potential for accompanying risks, side effects, and druginteractions. Therefore, it is critical that I tell my dentist of all medications I am currently taking, whichare:

8. I understand that every reasonable effort will be made to ensure the success of my treatment. There is arisk that the procedure will not save the tooth.

Consequences if no Treatment is Administered, Are Not Limited to the Following:

I understand that if no treatment is performed, I may continue to experience symptoms which mayincrease in severity, and the cosmetic appearance of my teeth may continue to deteriorate,

I have been informed of and accept the consequence if no treatment is administered.

Alternatives to Crowns, Are $! Limited to the Following:

I understand that depending on the reason I have a crown placed, altematives may exist. I have askedmy dentist about them and their respective expenses. My questions have been answered to mysatisfaction regarding the procedures and their risks, beneflts, and costs.Alternatives discussed:

No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure orimprove the condition(s) listed above.

r I consent to the crown preparation and placement as described above by Dr. James N. Angelos.

r I refuse to give my consent for the proposed treatment as described above.

Patient's Signature Date

I attest that I have discussed the risks, benefits, consequences, and alternatives of crowns with(patient's name) who has had the opportunity to ask questions, and I

believe my patient understands what has been explained.

Dentist's Signature Date

Witness' Signature Date