INFORMED CONSENT FOR COMPOSITE FILLING

I understand that the treatment of my dentition involving the placement of composite resin fillings, which may be more aesthetic in appearance than some of the conventional materials that have been traditionally used, such as silver amalgam or gold, may entail certain risks. There is the possibility of failure to achieve the desired or expected results. | agree to assume those risks that may occur, even if care and diligence is exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure of the filling associated with, but not limited to, the followin on me.

Sensitivity of Teeth Often after preparation of teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. The sensitivity can be mild or severe. The sensitivity can last only for a short period of time of last for much longer periods of time. If such sensitivity is persistent or lasts for an extended period of time, I will notify the dentist because this can be a sign of more serious problems.

Risk of fracture Inherent in the placement of replacement of any restoration, is the possibility of the creation of small fracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear at a later time.

Necessity for root canal therapy When fillings are placed or replaced, the preparation of the teeth often requires the removal of tooth structures adequate to ensure that the diseased or otherwise compromised tooth structure provides sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal, which often is exhibited by extreme sensitivity or possible abscess, root canal treatment of extraction may be required.

Injury to the nerves There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue of other oral or facial tissues from any dental treatment, particularly those involving the administration of local anesthetics. The resulting numbness that can occur is usually temporary. but in rare instances it could be permanent.

Aesthetics or appearance When a composite filling is placed, effort will be made to closely approximate the appearance of natural tooth color. However, because many factors affect the shades of teeth, it may not be possible to exactly match the tooth coloration, Also, the shade of the composite fillings can change over time because of a variety of factors Including mouth fluids, foods, smoking, etc. The dentist has no control over these factors.

Breakage, dislodgement or bond failure Because of extreme masticatory (chewing) pressures or other traumatic forces, it is possible for composite resin fillings or aesthetic restorations bonded with composite resins, to be dislodged or fractured. The resin-enamel bond can fail, resulting in leakage and recurrent decay. The dentist has no control over these factors.

New technology and health issues Composite resin technology continues to advance, but some materials yield disappointing results over time and some fillings may have to be replaced by better, improved materials, some patients believe that having metal filings replaced with composite fillings will improve their general health. This motion has not been proven scientifically and there are no promises or guarantees that the removal of over fillings and the subsequent replacement with composite fillings will improve, alleviate or prevent any current or future health conditions.

Informed consent
I understand that it is my responsibility to notify this office should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed. | have been given the opportunity to ask any questions regarding the nature and purpose of composite fillings and have received answers to my satisfaction. | voluntarily accept any and all possible risks, including the risk of substantial harm, if any. that may be associated with any phase of this treatment in hopes of obtaining the desired outcome, by signing this document, I authorize Dr and /or his/her associates to render any services deemed necessary of advisable in the treatment of my dental condition, including the prescribing and administration of any medically necessary anesthetic agents and/or medications.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.