Dentistry On 66

INFORMED CONSENT FORM CROWNS, VENEERS OR BRIDGES


ALTERNATIVE TREATMENT (discussed only as they apply)
 Tooth-coloured filling
 Dental Implants
 Removable Partial Denture
 Removable Complete Denture

RISKS
 Tooth Sensitivity (short or long term)
 Possibility of root canal treatment if necessary
 Fracture or chipping of the crown/bridge/veneer surface
 Decay of the tooth at the gum line
 Recession of the gums-possibly exposing unsightly edges of the tooth
 Loss of the entire crown/bridge/veneer due to cement de-bonding or fracture/decay at the gum line
 Jaw Pain or discomfort requiring adjustment of the crown

By signing, I or the patient for whom I act as guardian/POA, understand and agree with the following statements:
 The above risks, benefits and alternative treatments have been discussed clearly
 Although success rates are very high there are no guarantees regarding the longevity or anticipated result
of the procedure.
 I understand the information discussed and have had the opportunity to ask questions.

d066 crown Vaneers
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