CONSENT FOR COSMETIC TREATMENT (Including bleaching, bonding, and veneer)

1. I understand that treatment of my dentition for which I desire cosmetic dental procedures to be performed, may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results that may be desired or expected. Even though care and diligence is exercised in the treatment, there are neither guarantees of anticipated or desired results nor any assurance of the longevity of the treatment.

   Tooth Number:

   I accept and understand those risks, possible unsuccessful results and/or failure associated with but not limited to the following:

   • Reduction or roughening of toothstructure
   • Jaw ridges that may not provide adequate support or retention.
   • Sensitivity of teeth: Even though in most cases (whitening, bleaching, bonding and veneering teeth) there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for anexamination
   • Chipping, breaking, or loosening of the veneer: No matter how well the veneer is placed, this could occur. Many factors may contribute to this happening, including chewing of hard materials, changes in occlusal (biting) forces over time, traumatic blows to the mouth, breakdown of the bonding agents and other conditions over which the doctor has nocontrol.
   • Sensitivity or allergic reactions to whitening, bleaching, or bondingagents.
   • Aesthetics/appearance: Every effort possible will be made to match and coordinate both the form and shade of veneers and/or bonding agents to be cosmetically pleasing to the patient. However, there are limited number of shades that can be mixed to match natural tooth color. This makes it impossible to have the exact shade and/or form to perfectly match your naturaldentition.
   • Longevity: It is impossible to identify any specific criteria on the length of time that veneers and bonding should last or for the lightened appearance of whitened or bleached teeth to maintain the lightened shades. These time periods may vary depending on many conditions existing from patient to patient as well as each patient’s individual habits orcircumstances.
   • Numbness following use ofanesthesia

2. I have been given the opportunity to ask all questions regarding the nature and purpose of cosmetic dental treatment and have received all answers to my satisfaction. I voluntarily assume all possible risks which may be associated with any phase of this treatment in hopes of obtaining the desired results. The fee(s) for these services have been explained to me. By signing this form, I am giving my consent to allow and authorize Dr._____________________and/or his/her associates to render any treatment deemed necessary, desirable and/or advisable to me, including the administration and/or prescribing of any anesthetics and/ormedications.

"I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies "