CONSENT FORM POST AND CORE

A post and core crown are a type of dental restoration required where there is an inadequate amount of sound tooth tissue remaining to retain a conventional crown. A post is cemented into a prepared root canal, which retains a core restoration, which retains the final crown.

In House Fiber Post:

Are manufactured from pre-stretched fibers impregnated within a resin matrix.

Lab Metal Post:

A metal that is inserted into the root space of the tooth is prepared in the lab by a technician.

  • I understand that certain factors must be considered to place a successful post and core.
  • These factors, including the quantity of tooth structure, the quality of tooth structure, the presence of adjacent tooth structures, post can detach, and the need for future restoration, can act as guidelines for the clinician.
  • I understand during the preparation for the post space there is a risk of perforation, a post can also make a tooth more likely to fracture, it makes future orthograde root canal treatment much more difficult and finally it is very destructive and requires excessive removal of tooth tissue.
  • Post and core procedures don’t reinforce or strengthen teeth.
  • In some instances, a post may stress or weaken your teeth over time.

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 to perform the treatment on me.



Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date