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.