Your Details Name*
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DOB* Consent Form Type*
Periodontal treatment consent Consent* We have discussed your diagnosis of periodontal gum disease and you understand that you need a course of periodontal treatment to stabilise your condition.*
Consent* Periodontal disease is an infection that affects the gum, ligaments and the bone that support the teeth.*
Consent* Periodontal treatment involves a number of appointments, each course of periodontal treatment is tailored to meet your individual needs. The treatment involves cleaning above and below the gums. The long term aim is to prevent the further development of gum disease and to prevent the loss of any teeth.*
Appointments may involve:* 1: Pocket charting and measurement of the bone levels
Appointments may involve:* 2: Oral hygiene instruction*
Appointments may involve:* 3: Deep cleaning of the tooth surface below the gum*
Appointments may involve:* 4: Medicating any deep pockets*
Appointments may involve:* 5: Laser therapy*
Consent* By using local anaesthetic and /or sedation where necessary, we take great care in making the treatment as comfortable as possible.*
Consent* Home care (by the patient) is vital to the success of the treatment.*
Consent* The Hygienist/Dentist will design a home care programme with you, explaining the use of different hygiene aids suitable to your diagnosis.*
Consent* As periodontal disease is an irreversible chronic condition, regular maintenance appointments are essential in preventing further bone and tooth loss.*
Consent* If there is no significant improvement, it may be necessary to refer you to a periodontist (gum specialist). The periodontist will re-assess your oral health and advise you on further complex treatment which may involve surgery of the gums.*
As with all medical procedures, there are risks and potential complications associated which you must be aware of before you proceed with treatment: Expected complications Numbness lasting a few hours.
Soreness of the gums lasting a few days.
Requirement for maintenance cleaning in the future.
Common Risks and complications:* Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:* Some teeth with have increased sensitivity for some time after the procedure.*
Common Risks and complications:* Inability to clean the tooth well enough to control the periodontal disease.*
Common Risks and complications:* Cosmetic changes to the gums.*
Rare Risks and complications 1:* Trauma to the tissues under the tooth including bone, sinus, nerves supplying the other teeth etc.
Rare Risks and complications 2:* Allergic reaction to something used during the procedure.*
Periodontal treatment is not 100% successful all of the time, even if all parts of the procedure go as planned. Therefore some teeth that have undergone this procedure will require further treatment or may require extraction. ConsentAlternative options:* 1- Referral to a specialist in this field who may be able to treat the tooth better via a microscope and specialist equipment.
ConsentAlternative options:* 2- Treating the tooth in a different way, such as extraction.*
ConsentAlternative options:* 3- Refusing any treatment, this will result in a high risk of further gum strength ultimately leading to the loss of some teeth.*
Do you consent to the treatment : Periodontal Consent Form* Informed consent to treatment: Periodontal Consent Form* I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Periodontal Consent Form* - I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Tooth Preparation procedures consent
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows:
I have been given all treatment options including no treatment, extraction(s), and restorations and have opted for: filling(s)/ Crown(s)/ Bridge(s) / Veneer(s) or………
I understand that having fillings, crowns/ bridges or veneers carries certain risks and these are outlined as follows:
Please Read and Tick* In order to make space for the filling/ crown /bridge/ veneer we will be reducing the amount of natural tooth structure. Our preparation will be done as minimal as possible to give you the best aesthetics and strength in your filling/ crown/ bridge/ veneer.*
Please Read and Tick* In reducing and roughening the tooth surface it is possible that irritation of the nerves may occur and this may cause sensitivity after the tooth is prepared and even after the restoration is completed. If it continues I am aware it may be necessary to perform root canal therapy on this tooth or in a worst case scenario remove the tooth, this may incur an additional fee.*
Please Read and Tick* Chipping, breaking or loosening of the filling/ crown/ bridge / veneer may occur at any time following the placement. Many factors may contribute to this happening such as chewing of excessively hard material, traumatic blows to the mouth, grinding or clenching of teeth and other conditions over which the dentist has no control.*
Please Read and Tick* Appearance: Every attempt possible will be made to match and co-ordinate both the shape and colour of the filling/ crown/ bridge/ veneers which will be placed to be cosmetically pleasing to you. However there are some differences which may exist between that which is natural and which is artificial, making it impossible to have the colour and or shape to match your natural teeth.*
Please Read and Tick* Longevity: It is impossible to place a specific time criteria on the length of time that fillings/ crowns/ bridges/ veneers will last.*
Please Read and Tick* If you have any issues with any work carried out here, we recommend that you call us immediately and give us the opportunity to rectify any issues and address any concerns you may have.*
Expected complications 1:* Numbness lasting a few hours.
Expected complications 2:* Soreness of the gums lasting a few days.*
Common Risks and complications:* Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:* Some teeth with have increased sensitivity for some time after the procedure.*
Common Risks and complications:* Darkening of the root of the tooth depending on the material used.*
Common Risks and complications:* Inability to return the tooth to a perfect shape which could result in the tooth being difficult to look after.*
Rare Risks and complications:* Removing tooth material to make space for a crown/veneer/bridge/filling can irritate the nerve inside the tooth, sometimes leading to the nerve dying and causing toothache.
Rare Risks and complications:* Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.*
Rare Risks and complications:* Allergic reaction to something used during the procedure.*
Expected complications* Numbness lasting a few hours
Crowns/veneers/bridges and fillings are not always 100% successful, even if all parts of the procedure going as planned. The tooth may not have enough strength left prior
to this procedure for good long term results. Decay and any previous work may have already irritated the nerve which could result in toothache in the future. Therefore some teeth that have undergone this procedure will require root canal treatment in the future, or may require extraction.
Alternative options:* Referral to a specialist in this field who may be able to treat the tooth better via a microscope and specialist equipment.
Alternative options:* Treating the tooth in a different way, such as extraction.*
Alternative options:* Refusing treatment, but this will result in a high risk of fracture/ pain or infection from this tooth.*
Do you consent to the treatment* Informed consent to treatment: Tooth Preparation procedures consent* I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
Informed consent to treatment: - I choose to refuse the advised treatment Tooth Preparation procedures consent* - I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Teeth Whitening Consent Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or are aware of an adverse reaction to this ingredient, please do not proceed with this treatment.
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* As with any treatment there are benefits and risks. The benefit is that teeth can be whitened fairly quickly in a simple manner. This method is the most cost effective and successful method currently available. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to whiten teeth is safe. There is new research indicating the safety for use on the soft tissues (gums, cheek, tongue and throat). The long-term effects are as yet unknown. Although the extent of the risk is unknown, acceptance of treatment means acceptance of risk.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* There have been instances where damage occurring to some teeth can cause extreme pain and require root canal treatment at a further cost to you, and could ultimately result in extraction of these teeth. This is very rare, you will generally get ulcers, soreness and irritation to the gum.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* The amount of whitening colour improvement varies with the individual and cannot be guaranteed. Most patients achieve a change within approximately 2 - weeks. It is important to reduce the consumption of tea, coffee, red wine, berries and curries during or after treatment for at least 1 month, and follow all the advice given by your dentist and in the advice sheet provided.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* It is advisable not to smoke during the course of whitening treatment and for at least 5 - 8 weeks afterwards.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* You may notice sensitivity after a few days of treatment. This is perfectly normal. If this should occur you can refrain from using the whitening treatment for 3 to 4 days, or follow the advice given to you by your dentist.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* Do not use the whitening treatment if you are pregnant. There have been no adverse reactions, but long-term clinical effects are unknown.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* You can wear the trays overnight or for a few hours during the day (e.g. whilst watching television in the evening).*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* After the desired amount of tooth whitening has been achieved, you may be requested to return to your dentist for a review appointment to check the results/shade achieved. It may be necessary to do a top-up treatment in 4 to 6 months or more, depending on the amount of staining and your diet.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* All existing restorations such as fillings, veneers and crowns will not whiten and these may need to be replaced for cosmetic reasons after teeth whitening at further cost to you and you accept this.*
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* If you are having any restorative work such as crowns, cosmetic fillings, veneers, bridges and implant treatment, teeth whitening must be stopped 2 weeks prior to any impressions and shade taking appointment to allow the teeth colour after teeth whitening to stabilise. Otherwise the final restorations will appear too white and may need replacing at further cost and time to you. You accept these risks and costs.*
Informed consent to treatment:* I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment. I agree to proceed with the recommended teeth whitening.
Please read and tick* I have informed my dentist of any underlying medical conditions.*
Please read and tick* Afterwards, the area may be sore and swollen, there is also a risk of infection, dry socket, bruising that can in rare cases extend as low as the neckline and bleeding after the tooth has been extracted.*
Please read and tick* I understand that after extraction, some bone will be lost in this area and may effect the other teeth. I have been advised on what can be done to minimise this.*
Please read and tick* The jaw muscles can be sore and stiff afterwards.*
Please read and tick* The area around the extraction site will be numb during and after the procedure, please avoid biting your lip and consuming hot food.*
Please read and tick* In cases of extracting the lower wisdom teeth, there is a risk of temporary or permanent numbness in the lower lip.*
Please read and tick* In cases of extracting some upper teeth, there is a risk of OAF (Oral Antula Fistula). Your dentist will explain this to you if applicable.*
Please read and tick* During an extraction, there is a small chance of damaging near by teeth.*
Please read and tick* There is a chance of the tooth breaking whilst trying to extract it, your dentist will endeavour to remove the remaining tooth, however may need to refer you to the hospital if it is in your best interests.*
Please read and tick* Stitches may be placed where clinically necessary to aid healing.*
Please read and tick* I have been informed of all my options for replacing the space once the tooth has been extracted.*
Please read and tick* I further understand that this procedure can also be performed by a specialist dentist and request that this treatment is performed at Parrock Dental by a general dentist.*
Please read and tick* The dental treatment to be carried out has been explained to me and I understand what the procedure entails.*
Please read and tick* I consent to the extraction proposed (including anaesthetic and any x-rays that need to be taken during the process).*
Expected complications:* Numbness lasting a few hours.
Expected complications:* Soreness, numbness and localised swelling lasting up to a week.*
Common Risks and complications:* Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:* Prolonged post operative pain caused by poor healing or infection.*
Common Risks and complications:* Fracture of the tooth during the procedure which can lead to a minor surgical proceeding being needed or a piece of the tooth being left because it cannot be removed.*
Rare Risks and complications: Trauma to the tissues under the tooth including bone, sinus, nerves supplying the other teeth etc.
Rare Risks and complications: A communication (hole) between the mouth and the sinus.
Rare Risks and complications: Displacement of part of the tooth into the sinus.
Rare Risks and complications: Allergic reaction to something used during the procedure.
Alternative treatment options:* 1- Referral to a specialist in this field who may be able to treat the tooth better with the use of specialist equipment etc.
Alternative treatment options:* 2- It may be possible to save the tooth with root canal treatment.*
Alternative treatment options:* 3- Refusing treatment, but this will result in high risk of further pain and infection from this tooth.*
Do you consent to the treatment : Extraction Consent Form* Informed consent to treatment: - Extraction Consent I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
I agree to proceed with the recommended extraction(s).
REFUSE Informed consent to treatment: Extraction Consent Form* - I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision. I refuse the above treatment and understand the possible consequences.
Denture Consent Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* The production of a denture is a procedure to create a removable prosthesis which is custom made for the individual to replace one or more missing teeth. I understand that there are alternative treatments to a denture such as dental implants to improve function and have been given that option.
As with all dental procedures, there are some risks and potential complications which you must be aware of before consenting to proceed with the treatment:* Dentures are a removable prosthesis that do not work exactly like natural teeth. They can be made of metal or plastic and clasps and rest seats to hold them in the mouth depending on the design by your dentist.
Please read and tick* Dentures must be removed for cleaning and kept out of the mouth during the night.*
Please read and tick* It is common that dentures (whilst in the mouth) can move or become dislodged whilst talking or eating, and food can get trapped/stuck underneath them.*
Please read and tick* Dentures can require adjustments, relining or remaking in the future due to changes in the shape of the gum changing over time.*
Please read and tick* Thorough denture hygiene and oral hygiene is required to keep your mouth healthy when wearing a denture.*
Common risks and issues with dentures:* Dentures can rub on the gums and cause ulcers, pain and discomfort.
Please read and tick* Some dentures can put additional stress on the remaining/adjacent teeth, fillings or crowns and can lead to further work being required in the future. Dentures attract more bacteria in the mouth and you may be at a higher risk of gum disease and tooth decay which can result in further treatment being required or tooth loss.*
Please read and tick* You may require new dentures to be made in the future due to further tooth or gum loss, poor fit or further work being required at a further cost to you.*
Please read and tick* Temporary dentures will not have the best strength, appearance and bite and will require a replacement in the future, at a further cost to you.*
Please read and tick* Dentures can be lost or broken resulting in further cost to mend or remake and also time with out denture whilst it is in the lab.*
Please read and tick* Dentures are not always successful, even if all stages of the treatment go as planned. You are paying for the dentist time and laboratory costs. If you require additional treatment it will be done at an additional cost to you.*
Please read and tick* Some people may not get on with dentures, even if they are technically sound and fit perfectly. The patient may then wish to replace the missing teeth in an alternative way.*
Alternative options to replace missing teeth: 1) Referral to a specialist in this field.
Please read and tick 2) Replace teeth with dental implant/s or bridgework.
Please read and tick 3) Take no action and leave the spaces as they are.
Please read and tick* I understand that once I have completed my final try in appointment and my work is sent to the lab in preparation for my final fit appointment, no changes can be made to the restorations past this point. I have confirmed I am happy to proceed. If, in the event that I am unhappy with the restorations once I have my final fit, I will be liable to cover the costs of the lab fees and surgery time incurred, and any further costs incurred to make any changes, should I request a refund or any modifications.*
Do you consent to the treatment : Denture Consent Form* Informed consent to treatment: - Denture Consent form I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
I agree to proceed with the recommended extraction(s).
REFUSE Informed consent to treatment: Denture Consent Form* - I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision. I refuse the above treatment and understand the possible consequences.
Root Canal Patient Consent Form Root canal treatment has been proposed and agreed with you. Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows;* The alternatives to root canal treatment are; to not have any treatment, or to remove the tooth/teeth and you are not keen on those options.
Please read and tick* Often a root canal is done to save the tooth when it becomes painful or swollen, due to infection.*
Please read and tick* It can take up to 1 or 2 visits to clean out the root system, in some cases more.*
Please read and tick* Pain and swelling can persist for a few days after each appointment or after completion. Occasionally the tooth may remain feeling different to how it was.*
Please read and tick* After the root canal treatment is competed a crown is recommended in weak teeth and back teeth to prevent the risk of tooth fracture.*
Please read and tick* Root filled teeth are more likely to break than non root filled teeth which is why we recommend a crown as soon as possible. If the tooth breaks extensively it may not be restorable, requiring removal.*
Please read and tick* Not all root canal treatments succeed; the success rate ranges from 60-80% on average. Re-root treatments are more complex with a higher risk of failure.*
Please read and tick* You may need re-treatment or the tooth may need to be removed if pain or swelling persists after treatment is completed.*
Please read and tick* With your consent you may be referred to a specialist if problems cannot be resolved, this will incur an additional fee.*
Please read and tick* Strong chemicals such as hypo chloride (mild bleach) are required to disinfect the tooth and with this are associated risks, such as burns, pain and discomfort, which are not common, and reduced with great care taken.*
Please read and tick* Breakage of files during the procedure is a risk and can happen, which could lead to failure.*
Please read and tick* Not all teeth are the same, sometimes it may not be possible to find, clean and fill every root canal perfectly.*
Please read and tick* Root canal treatment is not always 100% successful, even if all aspects of the procedure go according to plan. Therefore some teeth which have undergone this procedure may need to have the RCT re done, or may need to be extracted.*
Please read and tick* It is important to keep the treated teeth clean or the root canal may fail. We recommend at least 6 monthly visits to a hygienist.*
Informed consent to treatment Do you consent to the treatment* Informed consent to treatment: Root Canal Patient Consent I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Root Canal Patient Consent I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Dental Implant Pre-treatment Consent Additional procedures Treatment options, advantages and disadvantages:
The options were discussed in detail with you for replacing the missing teeth which included:
(Tick boxes if discussed with patient)
After a detailed discussion of all these options you wished to go for dental implant treatment After a detailed discussion of all these options you wished to go for dental implant treatment as you wanted fixed teeth without grinding and damaging the adjacent teeth or any risks of debonding as with adhesive bridges.
Bone loss and possible grafts option discussion* We discussed where the teeth have been missing, broken or infected and also the area/sites after extraction as well as cases of thin biotype gum and bone are at risk of some continual bone and gum loss over time even though there may be adequate bone for implant placement this can effect the final and long term appearance of the final restorations making them look longer than ideal and also lead to bone loss in the area over time exposing the metal of implants, posts and the final restorations.
Bone loss and possible grafts option discussion* To correct this may require the use of pink porcelain material to mimic lost gum and you had no objection to this.*
Bone loss and possible grafts option discussion* In areas or cases where the gum is thin there is a higher risk of gum recession sometimes showing the metal components or the teeth appearing longer than the adjacent teeth. To reduce this as best as possible a gum graft (connective tissue graft may be required from your palate and placed in the site. The donor site may be quite sore during the healing. You accepted this if required.*
Bone loss and possible grafts option discussion* To reduce bone loss risk as much as possible we discussed options including replacing any lost bone for optimum aesthetics with a bone graft using your own bone (autogenous) or a guide tissue regeneration procedure with material of pig and cow origin. I advised you to an autogenous bone graft was considered the gold standard for the most predictable result, however due to the additional morbidity associated with this procedure we agreed to proceed with the alternative guided bone regeneration procedure where required using material of pig and cow origin such as BioOss and BioGuide or a synthetic alternative such as Ethoss . You advised me you had no issues using these materials and consented to their use.*
Bone loss and possible grafts option discussion* The patient also accepts the risk that the gum and bone loss may still occur over time exposing metal of implants, post or restoration or that the final restorations may look longer or shorter than adjacent teeth in the final restoration-they accepted if this arises they may require further treatment for aesthetic reasons at additional cost and time to them.*
Bone loss and possible grafts option discussion* We discussed use of non metal/metal free components but due to the strength we agreed to use metal reinforced restorations and metal posts to reduce long term risks of fracture but accepting over time if the gum recedes these may become visible requiring further tx for aesthetic reasons at additional cost.*
Bone loss and possible grafts option discussion* The patient also accepts the possible risks we discussed of the grafts occasionally getting infected which may also cause implant failure and which can extend the treatment time and also lead to further bone loss which can lead to a poorer aesthetic final result or rarely implant failure.*
Risks and benefits of treatment discussed as follows: We discussed the risks and benefits of the implant treatment options in detail as follows:
Restorative phase For full jaw or mouth work such as all on 4/ all on 6 treatment: Fitting of final implant restorations and dental implant health discussion Maintenanceand monitoring of dental implants and teeth and mouth long term discussion • I advised you that it is essential that the dental implants are monitored and maintained after the completion of treatment. The survival rate of good quality dental implants (the root part of the new tooth) placed by an experienced dental surgeon and regularly maintained and monitored has been reported to be approximately 95+% over 10 years. However like natural teeth, fillings and crowns they require regular monitoring and maintenance as the oral environment subjects the teeth and implants to many harsh chemicals, acids and heavy forces during function which could have an adverse effect on their health and cause premature fracture, debonding or failure.
Platinum Dental plan details: Platinum Dental plan details: I agree and accept all the risks* Informed consent to treatment: Dental Implant Treatment Consent I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Root Canal Patient Consent I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Consent 1. Take 2 painkillers at home 1 hour before your implant surgery appointment time. (Ibuprofen 400mg each x2 tablets or if you can't take this then take paracetemol 500mg x2). If you are taking painkillers already discuss this with your dentist but usually take these instead.
Consent 2. Begin taking Arnica tablets (from Boots or Holland & Barrett) and Vitamin C and Vitamin D supplements 2 week before, and continue taking 2 week after your appointment, for optimum healing.
Consent 3. Make sure you have a good breakfast or lunch before your appointment to avoid feeling faint and anxious and in case you may not be able to eat for a few hours.
Consent 4. Continue taking all normal medications.
Consent 5. If you are undergoing any sinus surgery ensure you do not have a cold or flu symptoms. In some cases we may need to reschedule your appointments. If this is the case please discuss this with your dentist as soon as possible.
Consent 6. If you are a smoker, please try to stop smoking at least 2 weeks before surgery and for 2 weeks after.
Consent 7. If you have diabetes please ensure your sugar levels are within the normal range and are well controlled.
Consent 8. Both smoking and diabetes are risk factors in poor healing after surgery.
Botulinum Toxin Therapy for Wrinkle Correction Consent to treatment All foreseeable risks of botulinum toxin therapy listed above have been thoroughly explained to me. My questions regarding the treatment procedure, its potential side effects and contraindications were answered to my full satisfaction. I also had adequate time to consider my decision. I understand that I am free to revoke my consent at any time without the need to give any reasons. By placing my signature below, I declare my consent to cosmetic treatment with botulinum toxin type A.
X-Ray and Ct scan consent Consent - X-Ray and Ct scan consent I being a person of sound mind, hereby give my permission for the dentist named above to take any xrays or ct scans necessary for my dental treatment. I understand that these xrays or ct scans may be free of charge due to any current special offers. In the future if I decide I would like to request copies of any x-rays or ct scans then the normal fee will be applicable for having them taken and copying on to a disc.
All on Four Consent Consent* 1. I have been informed of and understand the purpose and nature of Implant surgery and what is required to place an Implant under the gum in the bone.*
Consent* 2. I have read and understand the information contained in the following documents:*
Consent* 3. I have been informed of alternative treatments to Implants and I have considered them but have decided to opt for Implants to replace my missing teeth.*
Consent* 4. I have been informed of the possible risks, side effects and complications of Implant surgery, which may include, but are not limited to, the following:*
a) Post-operative discomfort, swelling and/or bruising which may necessitate several days of home recuperation.
b) Heavy bleeding which may be prolonged and may require treatment.
c) Injury to adjacent teeth and/or fillings.
d) Post-operative infection which may require additional treatment.
e) Restricted mouth opening for several days or weeks.
f) Creation of an opening into the nasal sinus (a normal cavity situated above the upper back teeth), requiring additional surgery.
g) Bruising of the face and/or jaws.
h) Development of a persistent opening between the sinus and the mouth.
i) Development or worsening of jaw joint symptoms.
j) Permanent or temporary numbness or altered sensation of the lip, tongue and/or cheeks.
k) Injury to the nerve underlying the teeth resulting in pain, swelling, numbness and/or tingling of the teeth, gums, lip, chin, cheek and/or tongue on the operated side. This may persist for several weeks, months or – in very rare instances – permanently.
l) Bleeding from the nose, which may occur soon after the surgery or subsequently.
m) Inhalation or swallowing of small Implant components during surgery, necessitating referral to a hospital for x-rays to confirm the position of the component and arrangement needing to be made for removal of the component unless it passes through naturally.
n) Need for additional surgery.
Consent* 5. I fully understand that either during and/or following the contemplated surgery, conditions may become apparent which warrant, in the judgment of the Dental or Implant Surgeon, additional or alternative treatment pertinent to the success of comprehensive treatment.*
Consent* 6. If any unforeseen conditions should arise in the course of the surgery which call for a medical practitioner’s judgment, I request and authorise the medical practitioner to do whatever he/she may deem advisable.*
Consent* 7. If at any time during surgery it is not possible to place Implants, I understand that the procedure will be discontinued and that there will be a charge for time spent and materials used.*
Consent* 8. I agree to modifications in design, materials and/or care if it is considered that this is in my best interest.*
Consent* 9. It has been explained to me that there is no method of accurately predicting the gum and bone healing capability in each patient following the placement of Implants.*
Consent* 10. No guarantee or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction.*
Consent* 11. I understand that sometimes Implants fail and must be removed.*
Consent* 12. I understand that excessive tobacco or alcohol or sugar consumption may delay the rate of healing and may also increase the chances of post-operative infection and of the proposed treatment failing.*
Consent* 13. I understand the importance of following a meticulous oral hygiene routine and agree to follow the home care instructions provided. I agree to attend regular dental examinations, reviews and hygiene appointments as instructed, for which there will be a charge.*
Consent* 14. I understand that, like natural teeth, Implants require routine maintenance and occasional treatment, such as gum treatment. I understand that there will be a charge for such maintenance and/or treatments.*
Consent* 15. I understand that Implants may indeed last many years if cared for properly but they are not guaranteed to “last a lifetime”.*
Consent* 16. I understand the importance of sticking to a soft, modified diet for the 4 months following surgery.*
Consent* 17. I understand that, in the unlikely event that an Implant fixture should fail to integrate in the jaw bone within the first 5 years after placement it will be replaced free-of-charge, subject to my suitability for repeat treatment and subject to the conditions stated in the document ‘Replacement of Failed Implants’, which I have read and understood. I understand that there will be a charge for any additional treatments required within the first 5 years.*
Consent* 18. I consent to photography of procedures for my dental records. I also consent to use of my clinical photographs, showing ‘before’ and ‘after’ shots of my teeth (not my full face), to be published on my Dentist’s website and/or social media pages (eg Twitter/Facebook) and/or used for marketing purposes (eg flyers, newsletters, magazine/newspaper articles, displays at the dental practice). I understand that my name will not be used nor my full face shown without my express prior written consent.*
Consent* 19. I certify that I have had the opportunity to read and fully understand the terms and words within the above consent to the procedure and in the various ‘Implants – Advice to Patients’ documents listed above.*
Consent* 20. I fully understand the procedure to be undertaken and have had the opportunity to raise any questions and concerns I may have, which have been answered to my full satisfaction.*
Elective removal of teeth: Some of your remaining upper and / or lower teeth were reasonably healthy and saveable or restorable but you wished clearly and were adamant to electively remove and replace them with dental implant treatment to achieve the best colour, appearance of teeth and gum and alignment and bite with your upper and /or lower jaws by having full jaw implants in the upper and/or lower jaws. This you felt was more cost effective in the future with the some teeth possibly requiring further restorative and implant treatment at further cost.
I agree to:* The Implant procedure that has been proposed and explained to me.
I agree to* The payment terms: to pay the total patient fee before the Implant surgery appointment.*
I have:* Informed the Dentist of any existing medical conditions and infectious diseases that are known to me.
I have:* Been fully informed of the nature of the treatment outlined above and of any likely risk, side effects or complications of the treatment and that any procedure in addition to the proposed treatment will only be carried out if necessary and in my best interests.*
I have:* Informed the Dentist of any existing medical conditions and infectious diseases that are known to me.*
I have:* Informed the Dentist of any previous or current psychiatric conditions or treatment.*
I have:* I agree to the placement of Dental Implants as advised and agreed.*
Composite bonding Consent Dental Bonding is a technique that has been used in cosmetic dentisry for many years and can transform your smile in just a single visit. The process involves the skillful use of the correct amount and colour of a “dental composite”, which is a mouldable material with a paste-like consistency made from acrylic resins and a variety of fillers, depending on the type used. Dental Bonding is an option that can be considered:
To repair decayed teeth (composite resins are used to fill cavities)
To repair chipped or cracked teeth
To improve the appearance of discoloured teeth
To close spaces between teeth
To make teeth look longer
To change the shape of teeth
As a cosmetic alternative to amalgam fillings
To protect a portion of the tooth’s root that has been exposed when gums recede.
Advantages
Dental bonding is among the easiest and least expensive of cosmetic dental procedures. Unlike the veneers and crowns, which are customised tooth coverings that must be manufactured in a lab, bonding usually can be in one visit. Another advantage, compared with veneers and crowns, is that the least amount of tooth enamel, if any, if required to be removed. Also, unless dental bonding is being performed to fill a cavity, anaesthesia is usually not required.
Disadvantages
Although the material used in dental bonding is somewhat stain resistant, it does not resist stains as well as porcelain. Another disadvantage is that the bonding materials do not last as long nor are as strong as other restorative procedures, such as crowns, veneers, or onlays. Additionally, bonding materials can chip and break off the tooth
Aftercare
Bonded teeth do not require special care. Simply follow good oral hygiene practices. Brush teeth at least twice a day, floss at least once a day, and see your dentist for regular professional check-ups and cleanings.
Because bonding material can chip, it is important to avoid such habits as biting fingernails, chewing on pens, ice or other hard food objects; or using your bonded teeth as an opener. If you do notice any sharp edges on a bonded tooth or if your tooth feels odd when you bite down, call Parrock Dental for further advice on 01474 537191
We will guarantee the placement of your composite bonding for the first 12 months after treatment with your understanding of all the above information and your acceptance of good oral health habits.
We highly recommend you attend our practice every 6 months to see one of our dentists to examine and ensure the health of your teeth and mouth and composite bonding and check your bite and also to see our hygienist every 3 months for hygiene and air polishing care to maintain the gum health and remove any stains and deposits from your teeth and bonding.
We cannot offer any guarantee of your dental treatment if;
If you fail to follow any of our advice given to you during or after treatment.
If you do not attend every 6 months for a dental examination and see our hygienist every 3 months for hygiene and air polishing treatments to remove any stains and deposit build up on your teeth and composite bonding.
If you grind your teeth and do not wear a night guard provided by our practice.
If there are any chips or breakages due to overloading caused by loss of back chewing teeth or grinding of teeth or overloading habits such as nail biting.
Staining of your bonding is normal and can happen and is dependent on your diet and dental habits. Composite Bonding may need polishing over time to remove some stains and sometimes the bonding will need replacing or redoing and this will be at further costs to yourself and normal charges will apply. To reduce staining we highly recommend you see our hygienist every 3 months and have air polishing and hygiene care.
Joining our Platinum Dental plan is the most cost effective way to maintain your bonding as it covers all dental examinations (twice a year), hygiene appointments (4 times a year) for dental hygiene treatment (excludes air polishing), and also includes whitening top up syringes and x-rays to check your teeth.
Consent* I declare I have understood and agree to the treatment being carried out. I have discussed cosmetic options and maintenance with my dentist/therapist and agree this is the best treatment for me. I fully consent to this treatment being carried out and abide by the aftercare advice.
We would be grateful if you could read the below and tick which photo/video disclosure you would be happy to consent to:*
Information And General Consent For Zygoma/ Full Arch Implant Procedure You are going to have a procedure involving Zygoma Implants. Therefore, you should understand the nature of the operation and most common risks involved. Surgery is not an exact science, and this consent form does not list all the possible complications that can be associated with the procedure. In addition, the surgeon cannot guarantee the results of the Implant procedure(s).
The Surgical procedure requires incision and reflection of the tissues (gums), removal of the bone to expose the sinus cavity, lifting of the sinus membrane, placement of Zygoma Implants and closure of the wound with stitches.
I have been informed of possible alternative methods of treatment, if any. The following stages of the treatment have been explained to me.
Contouring and reduction of bone and gum, will be carried out to improve the fit, function and cosmetic appearance of your bridge.
A prototype bridge may be in place for three to six months, there is always a small chance that immediately fixing the prototype bridge may not be possible on the day of your surgery, in which case you will be provided with a removable denture.
A final bridge will be placed after approximately a minimum of three to six months of healing.
This operation will be followed by a degree of discomfort, swelling, nasal and/or sinus stuffiness, and pain that may require 7 to 14 days of recuperation on average. Complete resolution of all symptoms may take 6 weeks or longer.
The potential risks have been explained to me, and that in this specific instance such operative risks include, but are not limited to:
Postoperative discomfort, swelling and bruising which may necessitate several days of home recuperation.
Heavy bleeding that may be prolonged.
Injury to adjacent teeth and fillings.
Postoperative wound infection, sinus infection.
Restricted mouth opening for several days or weeks.
Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
Postoperative bleeding, nosebleed.
Permanent or temporary numbness or altered sensation of the lip, tongue or cheeks.
Discolouration (black/blue) of face or jaws
Development of an opening between the sinus and the mouth.
Development or worsening of jaw joint symptoms.
This may persist forseveral weeks, months or, in remote instances, permanently.
Soreness of the corners of the mouth.
Inhalation or swallowing of small implant components during the surgery may occur, necessitating referral to a hospital for a chest x-ray to confirm the position of the component and arrangement may need to be made for removal of the component unless it passes through naturally.
Need for additional surgery.
If any unforeseen conditions should arise in the course of the operation, calling for a doctor’s judgement or for procedures in addition to or different from those now contemplated, I request and authorise the doctor to do whatever he may deem advisable.
No guarantee or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. Due to individual patient differences there exists a risk of failure, relapse, selective retreatment or worsening of my present condition despite the care provided.
If I am a smoker, grind my teeth, have diabetes, especially uncontrolled, or suffer with advanced gum disease I am at higher risk of implant and teeth failure and this means the success of your treatment cannot be guaranteed and if complications arise further costs and procedures may be required and you accept this.
I understand the importance of sticking to a soft diet for the first 3 months after surgery.
I certify that I have had an opportunity to read and fully understand the terms and words within the above consent to the operation and the explanation referred to.
I understand fully the procedure to be undertaken by Dr Trivedi and have had the opportunity to raise any questions and concerns I may have which have been answered to my full satisfaction.
Elective removal of teeth: Some of your remaining upper and / or lower teeth were reasonably healthy and saveable or restorable but you wished clearly and were adamant to electively remove and replace them with dental implant treatment to achieve the best colour, appearance of teeth and gum and alignment and bite with your upper and /or lower jaws by having full jaw implants in the upper and/or lower jaws. This you felt was more cost effective in the future with the some teeth possibly requiring further restorative and implant treatment at further cost.
Terms and Conditions for £100 off Dental Treatment Offer
Patient consent for Invisalign® orthodontic treatment Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Consent box* I have read, understand, and agree to the above.
Digital Smile Questionnaire 1. Are you thinking about improving your smile for a special occasion? 2. Have you previously had other cosmetic treatments, e.g. facial or dental treatments? If yes, please provide details Name
First
Last
3. Are you or have you been unhappy with any dental / cosmetic treatment received in the past? 4. What are your treatment goals? Please tick all that apply 5. Which treatments are you specifically interested in? Please tick all that apply 6. On a scale of 1-10, with 10 being very happy, how would you score your smile today? 7. Are you anxious about having dental treatment? 8. Do you have a budget in mind for your treatment? 9. Is anyone else involved in your decision to have treatment? (e.g. friend, partner, family member) 10. Do you have any concerns about your treatment? Please tick all that apply 11. How did you hear about Parrock Dental? (please tick one) Consent By signing this form, I agree to Parrock Dental's Terms and Conditions and Privacy Policy
Video(s)* Photograph(s)* Consent* I agree to the privacy policy.
Consent* I declare, in consequence of granting this permission, that I have no claim on ground of breach of confidence or on any ground in any legal system against (name of dentist above) in respect of the publication of the video(s), photograph(s) and written testimonial(s).**