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Consent for General Dentistry Form

Please Read and Complete the Form Below

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  • Examination and X-Rays - I understand that the initial visit may require radiographs to complete the examination, diagnosis and treatment plan. Elias Dental requires that radiographs be taken once a year for preventative care and diagnosis.
  • Local Anesthesia - Anesthetizing agents are injected into a small area or injected as a nerve block directly into a larger area of the mouth with the intent of numbing the area to receive dental treatment. Risks include but are not limited to infection, swelling, allergic reactions, hematoma, bruising, discoloration, headache, tenderness at the needle site, dizziness, nausea, vomiting, and cheek/tongue/lip biting can occur from the injection. It is normal for the numbness to take time to wear off after treatment, usually 2-3 hours. However, it can take longer, and rarely the numbness is permanent if the nerve is injured.
  • Medications - I have been informed and understand that antibiotics and other medications can cause allergic reactions causing redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness and/or lack of awareness and coordination. I understand that the failure to take medications as prescribed may increase the risks of continued aggravated infection, pain and potential resistance to effect treatment of my condition.
  • Changes In Treatment Plan - I understand that during treatment, it may be necessary to change or add procedures because of conditions found while working on my teeth that were not discovered during examination. The most common being root canal therapy following routine restorative procedures as well as restorative surfaces changing during fillings. I give my permission to Elias Dental to make any changes and additions as necessary.
  • Fillings - I understand that care must be exercised in chewing on fillings, newly placed fillings are commonly known to have sensitivity following placement for up to two weeks.
  • Removal of Teeth (Extraction) - I understand removing teeth does not always remove all infection if present and it may be necessary to have further treatment. I understand the risks associated with teeth extractions and will be provided with informed consent on the day of treatment.
  • Crowns, Bridges and Fixed Restorations - I understand that sometimes it is not possible to match the color or natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent restoration is placed. I realize that the final opportunity to make adjustments/changes to my new crown, bridge, or veneer (including shape, fit, color, size and placement) will be done before cementation at which additional charges may apply. The need for root canals cannot always be predicted or anticipated prior to permanent cementation.
  • Dentures (Complete or Partial) and Removable Appliances - I realize that full or partial dentures are artificial and constructed of plastic, metal, resin, and/or porcelain. The problems of wearing those appliances have been explained to me including but not limited to looseness, soreness, and possible breakage. I realize that the final opportunity to make changes to my appliance will be at the "wax try in". I realize that my new appliance will need adjustment for up to 4 weeks following initial delivery. It is my responsibility to call the office to let them know I have sore spots.
  • Endodontic Treatment (Root Canal) - I realize there is no guarantee that RCT will save my tooth. I realize that final restorations are needed following RCT and I will return to Elias Dental for the final restoration. Dr. Elias does not provide RCT at Elias Dental and all Root Canals are referred to a specialist.
  • Periodontal Treatment - I understand that periodontitis (gum disease) is a serious condition causing gum inflammation and/or bone loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including non-surgical cleanings, gum surgery and/or extractions. I understand the success of treatment depends in part on my efforts to brush and floss daily, receive regular cleanings as directed (3 cleanings per year) and follow the guidelines and recommendations of the hygienist.
  • Prevention and Diagnosis - I understand the importance of routine hygiene and care visits. At Elias Dental we believe that good oral health care is a combination of your at home care and professional care provided at your routine cleaning. Not only do we feel that getting your teeth cleaned every 6months is crucial to your overall health, but we believe radiographs and dental examinations are key elements to your health as well.
  • TMJ / Bite Splints - I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the joints of the lower jaw near the ear after routine dental treatment wherein the mouth is held in the open position. However, symptoms of TMJ associated with dental treatment are usually transitory in nature and well tolerated by most patients. I understand that should the need for treatment arise, then Dr. Elias will evaluate the pain and decide further treatment. Keep in mind that Dr. Elias is always one step ahead ofTMJ and most often has already diagnosed you or suggested that you wear a bite splint to prevent TMJ symptoms. Dr. Elias checks for TMJ at every routine preventative appointment.

I understand that the doctor is not responsible for previous dental treatment. I understand that, during treatment, previously existing dentistry may need adjustment and/or replacement. I realize that no guarantees of results or absolute satisfaction are possible with dental treatment. I have truthfully answered all questions about my medical history and present health conditions fully and truthfully. I have told Elias Dental or other office personnel about all conditions, including allergies. I will not hold Elias Dental, Richard J. Elias DDS or associates responsible for any errors or omissions I may have made. I also understand that it is my responsibility to inform Elias Dental of any changes in my personal or medical history. I hereby acknowledge that I have read and understand this consent and the meaning of its contents. All of my questions have been answered in a satisfactory manner and I believe I have all the necessary information to give informed consent for treatment. I further understand that this consent shall remain in effect until terminated by me in writing.

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