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.
I understand that there have been no guarantees given or implied of any sort by anyone as to
the results that may be obtained.
I understand that the above described treatment or procedure involves inherent risks.
As an alternative to this therapy, I may elect to alt treatment or no treatment.
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.
I consent to the administration of any anesthetic that the dentist (or his/her appointees) deems
necessary to provide proper treatment.
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.
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.