CONSENT FOR FINAL CEMENTATION FOR CROWN(S) / VENEER(S) / FIXED BRIDGE WORK

The nature and type of material used in Crown(S) / Veneer(s) / Fixed Bridge Work, for example porcelain fused to metal, all porcelain, etc. has been explained to me and it is my understanding that the material to be used is:

By signing below, I acknowledge and authorize the above listed material to be used in my mouth. I have been given the opportunity to view my Crown(S)/Veneer(s)/Fixed Bridge Work in place of prior to final cementation. I approve the color, shape, feel and overall appearance of my Crown(S)/Veneer(s)/Fixed Bridge Work.

I understand that once the Crown(S)/Veneer(s)/Fixed Bridge Work is placed in my mouth the factors of color, shape, fee, and overall appearance cannot be changed without additional and possibly significant time being taken and fees assessed.

I understand that removing cemented Crown(S)/Veneer(s)/Fixed Bridge Work may create the risk of injury or breakage to the underlying teeth.

By signing this consent for final cementation, I give my consent for final cementation and acknowledge my approval of the appearance and authorize the usage of the material cited above.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post-treatment instructions have been explained to me.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.