FULL / PARTIAL MOUTH REHABILITATION CONSENT FORM

I have been informed of the need to have a complex dental reconstruction based on my presenting condition including, but not limited to, complex diagnostics involving impressions and multiple dental radiographs, bite adjustment therapy, composite resin restorations, provisional crowns and/or bridges, and fixed crowns and/or bridges. Dental implants may be used to support prosthetic therapy, and removable denture or partial denture therapy may be necessary as part of provisional or definitive treatment for my dental condition. Bite splint therapy may be used as part of the diagnostic and maintenance phases of treatment, and multiple bite splints may be necessary.

I understand that due to the complexity and nature of a complex dental rehabilitation such as mine, it is not possible for the doctor or any staff to reasonably and predictably set an estimated time necessary for completion; however, I understand that it is not uncommon for this type of treatment to take more than a year to complete; it is also likely that continued maintenance and/or future retreatment may be necessary.

I understand that the fees for my treatment plan be billed for each phase of treatment, regardless of whether “standard billing practices” suggest global billing. For example, I understand that there will appear to be separate charges for provisional crowns and for definitive crowns. I understand that these fees may be high due to the complexity of the case. I also understand that the original treatment plan is an estimate based on the best predictions possible, and modifications to the treatment plan and associated fees based on necessary adaptations to my clinical condition may occur during treatment and are my financial responsibility.

The procedures used in the provision of care have been fully explained to me, and I understand them. I have been told that the success of the treatment depends upon several factors under my control, such as:

• Following recommended oral hygiene procedures
• Following diet, nutrition, and home care advice
• Cooperating in maintaining the crowns, bridges, or dentures
• Keeping office appointments

I further understand that despite all estimates of the success of the treatment, there are many personal and biologic factors that cannot be predicted in advance that may affect its success and estimated costs including, but not limited to, the possible need for

• Root canal treatment
• Extraction of natural teeth
• Possibility of the fracture of porcelain
• Composite resin
• Acrylic
• Need to re-make or repair the restoration
• Need to remove healthy tooth structure to accommodate a prosthesis
• Possibility of sensitivity to temperature and chewing
• Possibility of treatment by an adjunctive dental specialist
• Possibility of a loose fit necessitating use of dental adhesives for dentures

I also understand that provisional, or “temporary”, restorations are not definitive restorations, and that “permanent” definitive restorations may need repair or replacement at any time during their use. I understand that wear of dental materials, my periodontal health, my personal health, and the health of my musculoskeletal system may necessitate the need for extensive retreatment during my lifetime; multiple bite adjustments will likely be necessary to accommodate for biological changes. I also understand that TMJ problems can develop or exacerbate independently of any dental therapy during treatment or in the future, which may require additional treatment. I understand that costs of adjunctive or specialty care and future dental or medical care which exceed the original estimate for my dental treatment plan are my responsibility.

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.