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CONSENT FOR DENTAL RESTORATIONS AND CLEANINGS MOBLE DENTAL PROGRAM Patient’s Name: _________________________________________________________ My dentist has informed me that restorative and/or hygiene work needs to be done on my teeth. Prior to this, digital x-rays may be taken. This would be followed by any of the treatment options listed below: Restorative Permanent Fillings Temporary Fillings Deep Sedative Fillings Temporary Crowns Hygiene/Sealants Cleaning/Prophylaxis Cleaning/Debridement Deep Scaling Sealants In addition, I have been informed that Root Canal Treatment and Permanent Crown restorations are not provided by Operation Grace MN. Filling teeth and cleaning/scaling and applying sealants are routine dental procedures. However, there are risks to restorative procedures that include, but are not limited to the following: Injections to numb teeth may cause nerve damage, leading to temporary loss of sensation to teeth, lips, tongue or chin. In very rare cases, the loss in sensation may be permanent. This can apply to either restorative or scaling treatments. Removing decay and placing fillings can cause injury to the tissue inside the teeth, and they can be very sensitive after treatment. This may include (a) hot/cold food & beverage sensitivity, (b) sensitivity when chewing, (c) sensitivity when brushing, and (d) mild to moderate toothache. In rare cases tissue damage from restorative treatment is permanent and the restored tooth will continue to get worse. If this happens, you may need a Root Canal. Root Canals are not provided by Operation Grace MN. If your doctor has indicated that you are to receive a Deep Sedated Filling, your tooth may have a very large cavity, and there is a high chance that the tissue inside your tooth has already been damaged beyond repair. If this is the case, the tooth will not get better after the filling, and you will need a Root Canal to save the tooth. Root Canals are not provided by Operation Grace MN. If you are receiving Temporary Fillings, you will need to follow up with a private provider for a permanent filling or Permanent Crown. Operation Grace MN does not provide permanent crowns. Temporary Crowns usually do not hold up well long-term. Operation Grace MN does not provide permanent crowns. If you want a permanent crown, you will need to follow up with a private provider. After fillings are done, teeth tend to become weaker, and pieces can break off. Further treatment may be needed. Damage to adjacent teeth can occur during any of these procedures - quite rare, but it can occur. Swallowing of aspiration of a foreign body can occur during any of these procedures - quite rare, but can occur. Reaction to local anesthetic – quite rare, but can occur. I have read and understand the above, and have had all of my questions answered. _____ I give my consent for any of the above treatments ______ I do not wish to have any treatment I am aware that the above information may also apply to future dental work provided by Operation Grace MN. _________________________________________________________________ Date: _____________________________ Signature of Patient (parent of Guardian if patient is under 18 years of age) _________________________________________________________________ Date: _____________________________ Signature of Doctor (revised 1/16) ................
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