New patient forms

1. Drugs, medications and anesthesia

I understand that antibiotics, analgesics and other medications may cause adverse reactions, some of which are, but are not limited to, redness and swelling of tissues, vomiting, dizziness, miscarriage and cardiac arrest. I understand that medications, drugs and anesthetics may cause drowsiness and lack of coordination, which can be increased by the use of alcohol or other drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medications and/or drugs, or until fully recovered from their effects (this includes a period of at least twenty-four (24) hours after my release from surgery). I understand that occasionally, upon injection of a local anesthetic, I may have prolonged persistent anesthesia, numbness and/or irritation to the area of injection. I understand that if I select to utilize nitrous oxide, Atarax, chloral hydrate, Xanax or any other sedative, possible risks include, but are not limited to, loss of consciousness, obstruction of airway, anaphylactic shock and cardiac arrest. I understand that someone needs to drive me home from the dental office after I have received sedation. I also understand that someone needs to watch me closely for a period of 8 to 10 hours following my dental appointment, to observe for possible deleterious side effects, such as obstruction of airway.

2. Hygiene and periodontics (tissue and bone loss)

I understand that the long-term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e. brushing and flossing) and maintaining regular recall visits. Periodontics: I understand that I have a serious condition, causing gum and bone inflammation and/or loss, and that it can lead to loss of my teeth and other complications. The various treatment plans have been explained to me, including gum surgery, replacement and/or extractions. I also understand that although these treatments have a high degree of success, they cannot be guaranteed. Occasionally, treated teeth may require extraction.

3. Removal of teeth

I understand that the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissue. The doctor has advised me that if this condition persists without treatment or surgery, my present oral condition will probably worsen over time. Potential risks include, but are not limited to, the following: A. Post-operative discomfort, swelling, prolonged bleeding, tooth sensitivity to hot or cold, gum shrinkage (possibly exposing crown margin), tooth looseness, delayed healing (dry socket) and/or infection (requiring prescriptions or additional treatment, i.e. surgery). B. Injury to adjacent teeth, caps or fillings (requiring the recommendation of crowns, replacement of fillings, fabrication of crowns, or extraction), or injury to other tissues not within the described surgical area. C. Limitation of opening; stiffness of facial and/or neck muscles; change in bite, or temporomandibular joint (jaw joint) difficulty (possibly requiring physical therapy or surgery). D. Residual root fragments or bone spicules left when complete removal would require extensive surgery or needless surgical complications. E. Possible bone fracture which may require wiring or surgical treatment. F. Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery. G. Injury to the nerve underlying the teeth resulting in itching, numbness or burning of the lip, chin, gums, cheek, teeth and/or tongue on the operated side; this may persist for several weeks, months or, in remote instances, permanently.

I give my consent for the doctor to perform the treatment/procedure/surgery for teeth # ______________, or other procedures deemed necessary or advisable to complete the planned operation. If any unforeseen condition should arise in the course of the operation, calling for the doctor's judgment or for procedures in addition to or different from those now contemplated, I request and authorize the doctor to do whatever he or she may deem advisable, including referral to another dentist or specialist. I also understand that the cost of this referral would be my responsibility.

4. Fillings

I have been advised of the need for fillings, either silver or composite (plastic), to replace tooth structure lost to decay. I understand that with time fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post and build-up, and crowns), which would necessitate a separate charge. I understand that the silver amalgam restoration is an acceptable procedure according to the American Dental Association guidelines. The advantages and disadvantages of alternative materials have been explained to me.

5. Endodontic treatment (root canal therapy)

The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative treatments, and the consequences of non-treatment. I understand that following root canal therapy my tooth will be brittle and must be protected against fracture by placement of a crown (cap) over the tooth. I understand that treatment risks can include, but are not limited to, the following: A. Post-treatment discomfort lasting a few hours to several days, for which medication will be prescribed if deemed necessary by the doctor. B. Post-treatment swelling of the gum area in the vicinity of the treated tooth, or facial swelling, either of which may persist for several days or longer. C. Infection. D. Restricted jaw opening. E. Breakage of root canal instruments during treatment, which may, in the judgment of the doctor, be left in the treated root canal or bone as part of the filling material, or may require surgery for removal. F. Perforation of the root canal with instruments, which may require additional surgical treatment or result in premature tooth loss or extraction. G. Risk of temporary or permanent numbness in the treatment area. If an "open and medicate" or pulpotomy procedure is performed, I understand that this is not permanent treatment, and I need to pay for and finish final root canal therapy. If root canal treatment is not finalized, I expose myself to infection and/or tooth loss. If failure of root canal therapy occurs, the treatment may have to be redone, root-end surgery may be required, or the tooth may have to be extracted.

6. Crowns and bridges (caps)

I understand that sometimes it is not possible to match the color of the natural teeth exactly with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur, necessitating possible root canal therapy. I understand that, like natural teeth, crowns and bridges need to be kept clean, with proper oral hygiene and periodic cleaning; otherwise decay may develop underneath and/or around the margins of the restoration, leading to future dental treatment.

7. Dentures, complete or partial

The problems of wearing dentures have been explained to me, including looseness, soreness, possible breakage, and relining due to tissue change. Follow-up appointments are an integral part of the maintenance and success of a prosthetic appliance. The doctor should immediately examine persistent sore spots. I further understand that surgical intervention (i.e. tori [bone] removal, bone recontouring, or implants) may be needed for dentures to be properly fitted. I also understand that due to bone or other complicating factors, I may never be able to wear dentures to my satisfaction.

8. Pedodontics (child dentistry)

I understand that the following procedures are used to treat pediatric patients and are accepted in the dental profession. A. Positive reinforcement: rewarding the child who shows desirable behavior with compliments, praise, a pat or hug, and/or token objects or toys. B. Voice control: the attention of a disruptive child is gained by changing the tone or increasing the volume of the doctor's voice. C. Hand-over-mouth exercise: the disruptive child is told that a hand is to be placed over the child's mouth. When the hand is in place, the dentist speaks directly into the child's ear and tells the child that if the disruptive noise stops, the hand will be removed. When the noise stops, the hand is removed and the child is praised for cooperating. If the noise resumes, the hand is again placed on the mouth and the exercise repeated. At no time is the airway ever restricted. D. Physical restraint: restraining the child's disruptive movements by holding down their hands, upper body, head and/or legs by use of the dentist's or assistant's hand or arm, or by use of a special device (referred to as a "papoose board"). E. Nitrous oxide and/or oral sedation: nitrous oxide is a mild gas that is mixed with oxygen and used to sedate a person. It is administered through a mask placed over the child's nose. Oral sedation is medication given to children to help them relax. With their use, the parent or guardian must understand that the child should not eat or drink for a period of four hours prior to the sedation appointment. The parent or guardian must be available to escort the child home after the sedation procedure, and observe their behavior throughout the day. I understand that with the use of an injection used to numb the tooth for dental procedures, the possibility exists that the child may inadvertently bite their lip, causing injury. I understand the need to return to the office for evaluation if swelling and/or pain in my child does not go away after a sufficient period of time. I understand the need to return to the office within three months following nerve treatment of a "baby tooth" for evaluation, and the possibility of it then needing an extraction.