New Patient Information Form

Dr. John J. Moynihan

Please correct the errors described below.

Dentistry is not an exact science and reputable practitioners cannot properly guarantee results. Despite the most diligent care and precaution, unanticipated complications or unintended results, although rare, may occur. A treatment plan is based on the best evidence available during the examination. There is no guarantee that this plan will not change. During treatment, it may be necessary to change or add procedures because of conditions that were not evident during examination, but were found during the course of treatment. Guarantees and assurances cannot be made by anyone regarding the dental treatment which you have requested and authorized. It is essential that you keep your appointments and cooperate in your treatment to help insure the best possible results.

Please read the following. Initial and sign where noted.


Care must be exercised in chewing on filled teeth, especially on large filling and during first 24 hours, to avoid breakage. A more extensive restoration procedure than originally diagnosed may be necessary, due to more decay than anticipated. Sensitivity can occur following a newly filling and will usually go away with time.

Crowns, Bridges and Laminates:

These restorations involve permanent alteration of the tooth structure. It is not always possible to match the color oft the natural teeth exactly with artificial teeth. Temporary restorations may come of easily. Care must be taken to insure that they are kept on until the permanent restorations are delivered. The final opportunity to make changes to the new crown, bridges or laminates (including the shape, fit, size and color) will be before cementation. It is necessary to keep the appointment for permanent cementation. Excessive delays may allow for tooth movement, necessitating the remaking of the restoration and additional charges may be incurred.

Dentures & Partials:

The wearing of dentures can be difficult. Sore spots, altered speech and difficulty in eating are common problems. Due to jaw ridge loss, retention of full dentures can be a problem. Immediate dentures may require considerable adjusting, A permanent reline will be needed later (This is not included in the denture fee). Failure to wear dentures every day will likely lead to tooth movement, resulting in a denture that no longer fits.

Periodontal Disease

This is a serious, progressive infection, causing breakdown of the gums and bone that support teeth. It is best treated in its early stage. Treatment options may include gum surgery, extractions and replacements. Undertaking and dental procedure may have a future adverse effect on the periodontia.

Endodontic Treatment (Root Canal)

Although over 90% effective, there is no guarantee that root canal treatment will succeed and complications can occur. Endodontic files and rare very fine instruments can separate during use. Additional surgical procedures may be necessary following root canal treatment. Despite all efforts to save it, the tooth may still be lost.


Teeth may need to be removed for various reasons. There are risks involved in having teeth removed, including, but not limited to pain, swelling, spread of infection, dry socket, loss of feeling in the lips, tongue and surrounding tissues (which is usually temporary, but in rare cases in permanent) sinus involvement and jaw fracture. If complications arise during or following treatment, referral to a specialist may be needed, requiring father treatment and additional cost.

Drugs, Medications and Anesthetics

Antibiotics, analgesics, natural supplements and other medications can cause allergic reactions such as redness and swelling of the tissue, pain, itching, vomiting and/or anaphylactic shock. Injection of local anesthetics can cause paresthesia (numbness) of teeth, lips and surrounding tissues. Though quite rare, this numbness can sometimes be permanent. Studies have shown that Bisphosphonate (ex. Fosamax) therapy for osteoporosis can compromise treatment results.

Appointment Cancellation Policy

An appointment in our schedule is a bond of trust that we will be here to serve you and you will be present for treatment. We strive to create a schedule that most efficiently provides for the dental needs of all of the patients we serve.

Please arrive on time to your scheduled appointment. Late arrivals cause schedule delays for those patients who arrive promptly at their appointment time. Late arrivals will be worked into the schedule if time allows or re-appointed to another day.


Additionally, while we understand that things may come up, It's very important that we receive notice of a change in plans at least 24 hours in advance.

We respect our patient's time and make every effort to remain on schedule. Some visits are more complicated than initially anticipated, and emergencies may arise that could delay us. If we are significantly delayed, we will notify you beforehand so you may choose to come later or reschedule. If you are going to be late, we ask that you please notify us. If you are significantly delayed, your scheduled treatment may be modified or you may be asked to rechedule your appointment.

Cancellation Policy

Because of the level of service we provide our patients, your appointment is especially held just for you, so that we have the right amount of time for your procedure at our office.

We ask that you make every effort to give us at least 24hr notice if you cannot make your scheduled appointment. It is our policy to charge any patient $49.00 for a broken appointment at our discretion.
Thank you for understanding the value of our policies.

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