ProSites, Inc.



GENERAL CONSENT FORMPatient Name: _____________________________________** Please read this form before you sign it. **You have the right to accept or reject dental treatment recommended by your dentist. This form is intended to provide you with an overview of potential risks and complications. Prior to consenting to treatment, you should carefully consider the anticipated benefits, commonly known risks and complications of the recommended procedure, alternative treatments or the option of no treatment.Medical History InformationPlease understand that it is important that you divulge any information about your medical history to your dentist. It is important that you inform us of any medicines that you are taking each time that you come to an appointment as some medications can cause harmful reactions with dental anesthetics, analgesics, antibiotics or other medications. Please be sure to provide us with a list of any drug allergies you have. It is very important that you provide your dentist with an accurate medical history before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled follow up appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Please read the items below and sign at the bottom of the form. Do not sign this form or agree to treatment until you have read, understood and accepted each item carefully. Be certain your dentist has addressed all of your concerns to your satisfaction before commencing treatment. I have informed the dentist of any known allergies I may have. I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling tissues; pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic or medication that may have been given to me in the office for my care. I understand that failure to take medications prescribed to me as directed may offer risks of continued or aggravated infection, pain or negative result on the outcome of my treatment. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth control pills).Examinations and X-raysRadiographs are required to complete your examination, diagnosis and treatment plan. A periodic examination will be provided by the dentist at all routine cleanings to evaluate your teeth for decay, gum disease, oral cancer and overall health. The dentist will read and diagnosis any x-rays taken. In the state of Massachusetts a dental hygienist cannot diagnose a patient. Modern dental x-ray equipment is extremely low-dose radiation. Diagnostic x-rays provide the dentists with valuable information about your teeth and supporting bone that cannot be evaluated otherwise. Our office takes the minimum x-rays to allow us to do a thorough exam for each patient. All patients 18 years and older will receive a full mouth series of intra-oral x-rays. Without these x-rays, we cannot do a complete exam of the entire mouth and jaw. We may also take photos of our patients as part of their permanent record. We will not release these photos to anyone without your permission. Dental Prophylaxis (cleanings)A routine dental prophylaxis involves the removal of plaque and calculus about the gum line and will not address gum infections below the gum line called periodontal disease. Some bleeding after a cleaning can occur, however, should it persist and if it severe in nature the office should be contacted. RestorationsI understand that care must be exercised in chewing on fillings until directed by doctor or staff to avoid breakage or soft tissue damage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay or unsupported tooth structure that can only be found during preparation of the tooth. This may lead to root canal, crown or both. Sensitivity is a common aftereffect of a newly placed filling. Occasionally after receiving a filling it may feel high and you may need to return to have the bite adjusted. Crowns, Bridges and VeneersIt is not always possible to match the color of natural teeth exactly with artificial teeth. A temporary crown will be made after the initial preparation appointment. Temporary crowns may come off and you should be careful chewing until the permanent crowns are delivered. If a temporary crown should fall off call the office immediately. The final opportunity to make changes on crowns, bridges or veneers (including shape, fit, size, placement and color) will be done before permanent cementation. In some cases, crowns, bridges and veneer procedures may result in the need for a future root canal treatment, which cannot always be predicted or anticipated. After a crown, bridge or veneer is permanently cemented sometimes your bite may feel high and you may need to return to have the bite adjusted or fixed. Modification of daily cleaning procedures may be required and if so will be explained to you by your provider. Periodontal TreatmentPeriodontal disease is an infection causing gum inflammation and/or bone loss that can lead to tooth loss. At times when a routine cleaning is scheduled the dental hygienist and dentist may discover periodontal disease is present in all or certain area of your mouth. If you present with an infection during your routine cleaning appointment it may be necessary for more extensive treatment to be performed. The dental hygienist will stop the routine cleaning and explain to you alternative treatment plans including nonsurgical cleaning below the gum line, placement of an antibiotic below the gum line or a gross debridement (two part cleaning). If further treatment such as gum surgery and/or extractions of any periodontal treatment depends in part on your efforts to brush and floss daily, receive regular cleanings as directed, follow a healthy diet, avoid tobacco products and follow any other recommendations. Some bleeding after deep cleanings or scaling under the gum line can occur, however, should it persist and if it is severe in nature the office should be contacted. Untreated periodontal disease may have a future adverse effect on the long term success of dental restoration work.Temporomandibular Joint Dysfunction (TMD)Symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment when the mouth is held in the open position. However, symptoms of TMD associated with dental treatment are usually temporary in nature and well tolerated by most patients. If need for treatment should arise, you will be referred to a specialist, the cost of which is your responsibility. Specific Problem ExaminationsIn the event that a patient requests only a specific problem be addressed (i.e.: broken tooth, pain in one area, etc.) this is considered a problem focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive examination will not be done. The dentist cannot diagnose problems in other areas of the mouth. Please understand that this appointment will be for the treatment/diagnosis of an emergency/urgent need. Any future treatment of other areas will require additional x-rays and a complete exam. You will not be considered a patient of record unless this examination is completed. Local AnesthesiaThe benefits one can expect from local anesthesia include pain control during and after a dental procedure. Nevertheless, the administration of local anesthesia and its performance carries certain risks, hazards, and unpleasant side effects which are infrequent, but nevertheless may occur. They include, but are not limited to the following: bleeding; infection; allergic reaction; nerve damage or paresthesia; facial paralysis; a temporary, increased heart rate and/or a flushed feeling; hematoma or swelling near or at the infection site; trismus or difficulty opening jaw for a short time after the injection; soft tissue damage after the dental procedure (due to biting of tongue and cheek, or burning tissues with hot food or beverage while still numb); sloughing of tissue; ocular complications; and needle breakage. Changes in Treatment PlanI 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, for example, root canal therapy following routine restorative procedures. I give permission to the Dentist to make any/all changes and additions as necessary after consultation. ComplicationsComplications resulting for the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections include (but are not limited to) swelling, sensitivity, bleeding, pain, infection, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth (which is transient but on infrequent occasion, may be permanent), reaction to injections, changes in occlusion (biting), jaw muscle cramps and spasms, temporomandibular (jaw) difficulty, referred pain to ear, neck, and head, nausea, vomiting, allergic reactions, delayed healing and treatment failure. The risks or complications from medications used/prescribed with general dental treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nausea, allergic reactions, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). [It is not advisable to operate any motor vehicle or hazardous device while experiencing side effects of the medications we may prescribe.] [Antibiotics are known to decrease the effectiveness of oral contraceptives, so it is advised that other contraceptive measures be taken during the administration of antibiotics.]MinorsWe must receive written consent prior to performing any non-emergency dental procedures on a minor. Grandparents, step-parents, friends, relatives, etc. are not legally allowed to consent to dental procedures, unless they have been given written consent by the parent or legal guardian. Please do not send your child to an appointment alone or with someone other than yourself, unless you have written note stating the office can treat your child, otherwise we may have no choice but to reschedule your child’s appointment to another day.Requests for records/x-raysBy law we are required to keep a patient’s original x-rays and record in this office. Original x-rays or records will NOT be released. The patient or a designated person may request copies of their x-rays or record, however, you will need to fill out a release form. We also require a minimum of 5-days notice to copy x-rays. Specialty Referral and/or second opinionGeneral dentists perform the majority of all dental treatment today. However, we want all patients to be aware that specialty fields exist in dentistry, particularly in oral surgery, orthodontics, periodontics, pediatric dentistry, and endodontics. In some cases we may have to refer certain procedures out to a specialist. We would be happy to offer you the names of specialists in order for you to have a second opinion and/or have actual treatment performed by a specialist. Consent/AuthorizationI hereby authorize the dental staff of Balian Family Dental to proceed with and perform the dental treatment as explained to me. I understand that this treatment is subject to modification depending on unforeseen or diagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of dental fees. A $50 broken appointment fee will be charged for any broken and/or last minute cancellations. We require 48 hours notice of cancellation. Payment is due when services are rendered. Finance charges will occur on balances 30 days and older. Delinquent accounts will be handled by a collection agency.I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that 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 allow the dental staff of Balian Family Dental to take x-rays and perform an examination on me today. I certify that I have read and fully understand the above consent to dental treatment and that anything that I did not understand has been explained to me. I further certify that I consent to recommended treatment as needed and understand the anticipated benefits and commonly known risks and complications of each procedure.Patient or Guardian Signature: ________________________________________ Date: ______________Doctor Signature: _________________________________________ Date: ______________Witness Signature: _________________________________________ Date: ______________198120015049500 ................
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