1. Health Information
I agree to disclose all previous illnesses and medical history. Undisclosed medical information, current medications, allergies or illness are risk factors.
2. Drugs, latex and medicines
I understand that antibiotics and other medicines can cause allergic reactions and even life-threatening anaphylaxis. Also, some antibiotics interfere with birth-control pills. Latex allergy can cause rashes and itching. Epinephrine increases the heartbeat and, depending on my health, may be dangerous to me.
3. Needle stick
If someone is inadvertently stuck with a needle used on me, I consent to have blood drawn for analysis.
4. Fillings, Crowns and Un-anticipated Root Canals
Some teeth may need a root canal even after a simple filling. Fillings and crowns do take away tooth structure and a percentage of these teeth end up needing a root canal after the filling or crown is done.
5. Root Canals Can Fail
Root canals can fail and may require additional treatment or the tooth may not be salvageable and require extraction
6. Porcelain Crown, Veneers, Bonding and Cosmetic Fillings
Porcelain crowns, veneers, cosmetic bonding and composite fillings are aesthetically pleasing; however, I understand that if they chip or break after successfully in use, I am responsible for repairs or remakes. Once a crown, veneer, bonding or filling is placed, I understand the color cannot be changed.
7. Extractions and Surgery
I understand that all dental extractions or surgeries carry risks for example, a dry-socket following an extraction. Some risks are life threatening such as a post-surgical infection or anaphylaxis.
8. Fee for Additional or Specialty Care
I understand that I may need treatment beyond what was originally planned (a crowned tooth becomes painful and will need a root canal), or I may be referred to a specialist for additional care (root canal was not successful). I agree to be financially responsible for the additional or specialty care.
9. Insurance/Limitations of Insurance Coverage
I authorize Smiles on Trindle Dental Care to file claims on my behalf. There might be charges beyond what insurance will pay, deductible, copays or coinsurance that are my financial responsibility. I understand that what may be quoted as my portion (co-payment) is only an estimate. I agree to be financially responsible for what insurance does not cover.
10. Gum Treatments and Requesting “Just a Cleaning”
If I do not floss, smoke and/or have gum disease, I can expect to have a deteriorating gum condition. I agree that if I require gum treatment, I will not insist that I simply get a cleaning (prophylaxis).
If I am more than 10 minutes late for my appointment, I will reschedule and pay a broken appointment fee.
12. 24 Hour Notice for Cancellations
I agree to give 24-hour notice for cancellations or pay the broken appointment fee. (See financially policy for amount)
13. Requesting Record Transfers
Upon finding a new dentist, I will give the office 24 hrs to transfer records and provided a signed records release to authorize the transfer of records.
I do not expect guarantees in dental care. I have read the above and consent to treatment.