ഉപയോക്താവ്:Challiyan/dental consent

BHARATH DENTAL CLINIC, KSRTC ROAD, CHALAKUDY, THRISSUR, KERALA

DENTAL TREATMENT CONSENT FORM

Please read and sign the respective items below in the signature area

Patient Name OP number: Age: Sex:

Address:

WORK TO BE DONE

I understand that I am getting the following work done by the dentist or the specialist dentist and I have adequately explained about the procedure and its outcome and complications. (1) Filling (2) Bridges (3) Crowns (4) Extraction (5) Root Canals. (5)Surgical extraction of impacted tooth (6) Orthodontic Treatment (7) Clear aligner treatments

These procedures may be done under Local anesthesia using Lidocaine ( lignociane) injections and I am not allergic to the medication specified. ( Signature of the patient) …....…..…..………..….…….

DRUGS AND MEDICATIONS S

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching vomiting and/or anaphylactic shock and I may have to be hospitalized if severe reactions occur. Signature ...….…..….…..……..…...

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of condition found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures I give permission to the dentist to make any/all changed and additions as necessary. Signature ...….…..….…..……..…...

REMOVAL OF TEETH

Alternatives to removal have been explained to me (root canal therapy with crowns, and periodontal surgery or apicoectomy etc) and I authorize the dentist to remove the following teeth and any others necessary for reasons in paragraph #3 1 understand removing teeth does not always remove all the infection which is present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed and some of which are pain swelling spread of infection, dry socket loss of feeling numbness in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days of months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility. Signature ..…..……..….……..……..……...

CROWN BRIDGES AND CAPS Initial

I understand that sometimes it may be necessary to grind the opposing teeth to get better occlusion with the crown or bridges. I also understand that if the crowns are places on teeth which are not properly endodontically treated, sensitivity or periapical infection can occur in the future for which additional treatment may be necessary and I am willing to do such procedure if deemed necessary. I also understand sometimes it is not possible to match the color of natural teeth I will make sure the crowns and bridges are matching with my natural teeth satisfactorily before they are fixed permanently on to the abutment teeth and I will to claim to change the shades or form after they have been fixed. I am also aware that crown and bridges may break or chip off due manufacturing defects or accidents require additional preperations and manufacturing of new crown and brifges or repair of the old one may be necessary and it may incur additional costs. I also

understand that may be wearing temporary crowns which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered I realize the final opportunity to make changes in my new crown bridge. or cap (including shape, fit size and color) will be before cementation. Signature .….….….……..………..……..….….

DENTURES COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial constructed of acrylic metal, and/or porcelain The problems of wearing these appliances have been explained to me include looseness. soreness and possible breakage. I realize the final opportunity to make changed in my new dentures shape, fit size, placement, and color) will be the teeth in wax try in visit! understand that most dentures require relining approximately three to twelve months after initial placement. The cost of the procedure is not included in the initial denture fee. I also understand that if any part of the denture breaks it can irritate the oral tissues and can lead to serious problems if not corrected as soon as it is noticed. If any serious medical issues arises due to such sharp areas in mouth, I will be solely responsible of the issue. Signature ...…..….….….….…..…….….……..….….….

ENDODONTIC TREATMENT (ROOT CANAL)

I understand that the Root canal treatment is a procedure which removes, cleans and shape the root canal of tooth in order to save the tooth from being pulled out. Root canal treatment while being tooth saving procedure may not always be successful and can fail due to many reasons such as accessory canals, blocked or obliterated canals or severe curvatures of the root or instrument seperation which could not be removed or byepassed. I also understand that root canal treated tooth requires protection from occlusal bites using crowns if there is opposing tooth present and the root canal treated tooth can break horizontally or vertically necessitating removal of the same. Protecting such tooth with crown have been explained to me in detail and I take the responsibility if anything happens to the root canal treated tooth before the crowns are places. I also understand that if proper apical seal is not obtained, additional surgical treatment such as apicoectomy may be necessary on the root canal treated tooth. Signature ...……..……..……..….…..….…….…....

PERIODONTAL LOSS (TISSUE & BONE)

I understand that I have a serious condition causing gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions and I understand that undertaking any dental procedures may have a future adverse effect on my periodontal conditions. Signature..….….….…..….………….…….

CLEAR ALIGNER TREATMENTS

I understand that clear aligner treatments are based on computer prediction models and thremoplastic trays on them and the treatment is diagnosed based on the records and impression or scan taken by the dentist/or orthodontist and treatment plan is devised by the orthodontist/s of the manufacturing company. I have been adequately informed about the treatment modality and my co-operation which is required for the success of the treatment, failure of which may result in unexpected treatment results. I also understand that if I lose the trays, it may require to make new trays and will be chargeable. I am aware of the fact that if in case the trays are not fitting properly or results are not achieved inspite of wearing the aligners properly, new impression and follow up may be required to make new sets of trays. Signature...…..……..….…….....…...…..……..……..……...

I understand that dentistry is not an exact science and that therefore reputable practitioners cannot fully guarantee results acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authonzed I have had the opportunity to read this form and ask question My questions have been answered to my satisfaction I am signing below that have read and understood this form

(This authorization must be signed by the parent/nearest relative, in case the patients a minor or if the patient is not in a position to

I wish to proceed with the recommended treatment .….……..……..…..……..….….….….……………….

Name Name of the Parent/Guardian

Date

Signature Witnessed by, Name:

Signature

I confirm that have explained to the patient/ nearest relative of the patient the above mentioned points about the procedure and explained the merits and demerits of it.

Treating Dentist

Signature

Date

Witnessed by Signature

Date