You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your dentist and your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.
As with all medical procedures, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment. Even though many of these complications are rare, they can occur occasionally.
Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:
Pain, swelling, and discomfort after treatment;
Infection in need of medication, follow-up procedures, or other treatment;
Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums and tongue along with possible loss of taste;
Damage to adjacent teeth, restorations or gums;
The need for replacement of restorations, implants, or other appliances in the future;
An altered bite in need of adjustment;
Sensitivity is a possibility of a newly placed filling.
A more extensive filling than initially diagnosed may be required due to additional decay;
Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist;
A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed later if symptoms develop;
Allergic reaction to anesthetic, medication, or materials used;
Need for follow-up care and treatment, including surgery;
It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post-treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments.
The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.
If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.
This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications of recommended treatment with your dentist. Be certain all your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
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