Dental Procedures General Consent

Patient’s Name:

File No.:

DOB:

Mobile Number:

Doctor Name:

Visit Date:

I understand the purpose of this general consent is to inform me of risks and benefits that are common in many dental procedures.

I understand that every dental patient has the right to informed consent. That means that as a patient or as a legal guardian for a patient I should understand what treatment is being proposed, what the possible complications and risks are, and what the alternatives are to the treatment. Of course, one alternative for me is to do nothing, although that carries with it its own risks.

For routine fillings, dental cleanings, prescription of medications, I understand this includes but is not limited to: temporary soreness, temperature sensitivity, unusual reaction/allergy to medications given or prescribed. Also, medications have common side effects that are listed by the manufacturer. Further, if I am taking other medications, my dental medications could have an adverse reaction, and I need to fully disclose all of my medications to the dentist and pharmacist; this includes herbal supplements.

For the administration of local anesthetic, I understand that for many treatments and procedures I will be given a local anesthetic injection which may cause an adverse reaction or side effects which may include, but are not limited to cardiac stimulation, bruising, muscle soreness, temporary or rarely permanent numbness, or temporary or permanent injury to nerves and/or blood vessels which may cause hematoma (blood that leaves the capillary and collects in a confined area). In a certain percentage of cases patients have had an allergic reaction to the anesthetic.

I consent to x-rays and pictures taken to further assess and follow up with the course of my treatment, which may be used for study and case report purposes. I understand that some pictures may be used for awareness or social media without disclosing my identity.

For oral surgery, I understand that there is always a risk of a post-operative infection, nerve damage, and iatrogenic injury, (an injury that might arise from our treatment or advice). In rare cases, the complications from surgery can be permanent, disabling, or even cause death. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from holding my mouth open during treatment.

I understand that all treatments and procedures have a risk of separation or breakage of dental instruments which may become lodged in a gum or other soft tissue or aspirated. I understand that occasionally needles break and may require surgical retrieval. Should I experience any of these or other conditions during or following treatment, I will contact my dentist as soon as possible.

I understand that the practice of dentistry is not an exact science and my dentist offers no guarantees or assurances as to the outcome or results of treatment or surgery.

I have the right to ask my dentist for more information if I have any concerns about my procedures and the possible side effects or complications.

I am consenting to radiographs prescribed by my doctor in reason with what is medically necessary to assess my dental health. I also consent to a general cleaning in the event I am not diagnosed with gum disease.

My signature below confirms that I understand that no dental treatment is completely risk free, and that my dentist will take reasonable steps to limit any complications of my treatment and to provide competent dentistry with comfort and care. I understand that some after-treatment effects and complications tend to occur with regularity.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature