Veneer Consent Form

Veneers are custom made thin shells of tooth colored material. These shells are bonded to the front of the teeth and can be used to change their color, shape, size, or length. Benefits of veneers also include providing protection to teeth that have been weakened by decay, prior restorations, or root canal treatment.

At the first visit, the dentist may contour the cheek side of the tooth to make room for the veneer to fit on the tooth. A temporary veneer may be worn while the veneer restoration is being made by the laboratory.

Alternatives: Depending on my diagnosis, there may or may not be alternatives to a veneer restoration. Possible alternatives may be a tooth colored filling, a crown, or no treatment.

Risks: I have been informed and understand that there are certain risks associated with veneer restorations.

• Sensitivity- I understand that my teeth may become sensitive.
• I understand that once any prior fillings or decay has been removed, it may reveal a more severe condition of my tooth, which may require root canal treatment or extraction.
• I understand that I may notice slight changes in my bite, and/or stiff or sore jaws following treatment.
• I understand that I will be given a local anesthetic and in rare cases patients have had an allergic or adverse reaction to the anesthetic, or temporary or permanent damage to nerves and/or blood vessels from the injection.
• I understand that veneers are not usually repairable should they chip or crack.
• I understand that veneers may become dislodged and fall off. To minimize the chance of this occurring, I should not bite my nails, chew on pencils, ice, or other hard objects, or otherwise put pressure on my teeth. It is often recommended to wear a nightguard when sleeping to protect my veneers from clenching or grinding of my teeth.
• I understand there is a risk of aspirating (inhaling) or swallowing the veneer during treatment.
• I understand that proper brushing and flossing, a healthy diet, and regular professional cleanings are essential to help prevent decay (cavities) and gum irritation.
• I understand that every effort will be made to match and coordinate the form and shade of veneers so they are cosmetically pleasing to me. However, there are some instances which may make it impossible to have the shade and/or form PERFECTLY match my natural teeth.

Acknowledgment

• I understand that once a veneer restoration is started, I must return promptly to have it finished.
• I understand it is my responsibility to immediately inform the doctor and seek attention from her should any unexpected problems occur, or if I am dissatisfied.
• I understand that all instructions must be diligently followed including scheduling and attending all appointments.
• I acknowledge that no guarantees have been made to me concerning the results of treatment.
• I acknowledge that I have had an opportunity to ask all questions regarding veneer treatment and have had all my questions answered to my satisfaction.

Consent

• I freely give my consent to the proposed treatment as described above.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.