CONSENT TO DENTAL TREATMENT

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.

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