CONSENT TO DENTAL TREATMENT


    Dentist:
    Dr. Donna Gentile

    Patient:


    1. I request and authorize above listed provider of service, and/or such other persons as he/she
      may appoint, to perform or assist in the performance of the dental treatment or procedures
      indicated below, which consists of but is not limited to:Fillings, Crowns, Bridges, Laminates,
      Dentures (Full or Partial), Periodontal Disease, Endodontic Treatment (Root Canal), Removal of
      Teeth (Extractions), Drugs, Medications and Anesthetics. I understand that the purpose of this
      procedure is treatment purpose.
    2. I understand that there have been no guarantees given or implied of any sort by anyone as to
      the results that may be obtained.
    3. I understand that the above described treatment or procedure involves inherent risks.
    4. As an alternative to this therapy, I may elect to alt treatment or no treatment.
    5. Further, it is understood that unforeseen conditions or circumstances may arise during the
      course of the above described procedures or alternate treatments. Therefore, I consent to
      authorize the performance of any care, procedure, or treatment not specified above that the
      dentist believes necessary or advisable as a result of these unforeseen events or conditions.
    6. I consent to the administration of any anesthetic that the dentist (or his/her appointees) deems
      necessary to provide proper treatment.
    7. I understand that there are risks involved with the administration of anesthesia. Antibiotics,
      analgesics, natural supplements and other medications can cause allergic reactions (redness,
      swelling, and or anaphylactic shock). Injections of local anesthetics can cause numbness of the
      teeth, lips, and surrounding tissues. Though quite rare, this numbness can sometimes be
      permanent. Bisphosphonate (ex. Fosomax) therapy for osteoporosis can compromise treatment.
    8. I have been given an opportunity to refuse to consent to any and all treatment or procedures
      specified in this form and have indicated my exclusions by drawing a line through the
      objectionable word(s), sentence(s), or paragraph(s), and writing my initials next to the portion
      to which I refuse to consent. I am also free to indicate at the end of this form anything not
      mentioned herein, but to which I refuse to consent.

    I certify that I have read and understand the above. I accept all risk of, if any, in hope of
    obtaining the desired beneficial results. I acknowledge that the dentist has explained all
    of the above to me in a manner to allow me to comprehend the consequences of my
    actions. Any questions about this treatment plan and its attendant risks have been
    answered fully and to my complete satisfaction.

    Date:

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    GentileDentalCare

    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

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    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.

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