Dental Treatment Consent Form

    Please read and initial the item below and sign the section at the bottom of the form

    1. Drugs and medications: I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction).
    2. Changes in treatment plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any /all changes and additions as necessary.
    3. Dental Radiograph: Dental radiograph allow the dentist to diagnose and treat conditions that cannot be detected during clinical examination. Dental X-ray films detect much more than cavities. For example, x-rays may be needed to survey erupting teeth, diagnose bone diseases, evaluate the results of an injury or plan orthodontic treatment. If dental problems are found and treated early, before they become visible or painful, dental care is much more comfortable and affordable.
    4. Removal of teeth: Alternative to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.) and I authorize the dentist to remove the necessary teeth for the treatment planned or for the reason in paragraph # 2. I understand the risk involved in teeth removal, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (paresthesia) that can be lost for an indefinite period of time or fracture jaw, I understand I should need further treatment by an specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.
    5. Crown, Bridge and caps: I understand that sometimes is not possible to match the color of the natural teeth exactly with artificial tooth, I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crown are delivered. I realize that opportunity to make changes in my new crown, bridge, or cap (including shape, size and color) will be before cementation.
    6. Prosthesis complete or partial: I realized that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness and possible breakage. I realize the final opportunity to make changes in my new dentures including shape, fit, size, placement and color will be the teeth in wax try-in visit. I understand that most dentures require relining approximately three to twelve month after initial placement. The cost for this procedure is not included in the initial denture fee.
    7. Endodontic treatment (Root canal): I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur form the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedure may be necessary following root canal treatment (apicoectomy).
    8. Periodontal loss (tissue and bone): I understand that I have serious condition, causing gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacement and/or extractions. I understand that undertaking any dental procedure may have a future adverse effect on my periodontal condition.
    9. Whitening: Advantage: Gives you a whiter smile. Teeth whitening can provide cosmetic enhancement for those seeking a whiter smile. This can give the teeth a healthier appearance, especially for those who drink coffee and smoke cigarettes. Advantage: Makes a Better Impression. Disadvantage: Can be Ineffective. Teeth’s whitening is not effective for everyone. Those with severely discolored teeth may have to rely on veneers. Can Cause Tooth Decay. The chemicals in some at-home teeth-whitening kits are corrosive to tooth enamel. They can cause serious, long-term damage if used improperly. Gives You Sore Gums and Teeth. Bleaching chemicals involved in the whitening process can cause sore gums and teeth and an increase in temperature sensitivity. The degree of chemical sensitivity varies from individual to individual and is usually only a short-term problem.

    I understand that dentistry is not an exact science and that, therefore, practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.




    I acknowledge that I have been provided with ELITE DENT ., “Notice of Privacy Practices”., and I am giving my consent for the use and disclosure of Protect Health Information as required and / or permitted by law.



    Purpose: This form is used to obtain your consent to communicate with you by email/mobile text messaging regarding your Protected Health Information. ELITE DENT., (ED) offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by /mobile text messaging has a number of risks that patients should consider before granting consent to use email/mobile text messaging for these purposes. ED will use reasonable means to protect the security and confidentiality of email/mobile text messaging information sent and received. However, ED cannot guarantee the security and confidentiality of email/mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

    I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of email/mobile text messaging between ED and me and consent to the conditions outlined herein. Any questions I may have had were answered.

    Patient Acknowledgment & Agreement