Informed Consent - General Dentistry Choosing among dentally reasonable treatment alternatives is a shared responsibility of dentists and patients. In the usual case, a dentist will recommend a course of treatment. While a patient often decides to adopt the recommendation, the ultimate decision is for the patient provided the choice is dentally reasonable. Under the law in New Jersey, a dentist is obligated to inform a patient of dentally acceptable treatment alternatives and their attendant probable risks and outcomes, and the costs relative to the treatment that is recommended and/or rendered, so a patient can make a decision that is informed. This form, together with our conversation about treatment alternatives, risks and outcomes, is intended to fulfill Dentist’s legal obligation to obtain informed consent. 1. Treatment Plan. The Dental Services to be provided include the following: 2. Changes in Treatment Plan. During the course of treatment, procedures may need to be added, expanded or changed because conditions are found that were not identified during examination and first were observed during the course of treatment. The most common include the need for root canal therapy and more extensive restorative procedures, like crowns, bridges or implants. Permission is hereby given to perform any additional or expanded dental services that the Dentist determines are necessary. Further, in the Dentist’s discretion, I may be referred to a specialist for further treatment, the cost of which is my responsibility. 3. Drugs, Medications and Sedation. Drugs, medications or anesthesia/sedation can cause allergic and other reactions. Examples include, but are not limited to, swelling, redness, itching, vomiting, diarrhea, numbness or tingling of the lip, gum or tongue (which in rare cases may be permanent) and also in rare cases, anaphylactic shock. Since they also may cause drowsiness and impair coordination or awareness, a motor vehicle or hazardous device should not be operated before full recovery is achieved. I have informed the dentist of all drugs and medications I am taking or have taken within the last 30 days as well as those that have been prescribed within the last 6 months but not taken, and all allergies and sensitivities of which I am aware. I have been informed and understand that failure to take drugs or medications as prescribed by Dentist may result in continued or aggravated infection and pain and potential resistance to effective treatment. In addition, antibiotics can reduce the effectiveness of birth control pills. 4. Fillings. The most common conditions encountered with fillings are pain, sensitivity to temperature or pressure, fractures of teeth or roots, nerve damage, damage to other teeth, occlusal (bite) discrepancies, temporomandibular joint problems and occasional allergic reactions to filling materials. 5. Endodontic Treatment (Root Canal). Although root canal treatment to retain a tooth or teeth that otherwise might need to be extracted is a very common dental procedure with a reported success rate over 90%, there are some risks and complications. The most common include swelling, soreness, infection, bleeding, trismus (restricted jaw opening), numbness or tingling of the lip, gum or tongue (which in rare cases may be permanent), discoloration of adjacent teeth or soft tissue, perforation of the root, and fractures (splits) of the crown or root of the tooth or restoration. Occasionally, one of the delicate instruments used to perform a root canal may break in the tooth. A failed root canal may require re-treatment, surgery or extraction. Once a tooth has received root canal treatment, it tends to be more brittle and weak. To minimize the likelihood of a fracture, restoration with a crown is recommended. There is no guarantee that root canal treatment will save a tooth. 6. Crowns, Onlays/Inlays, Bridges, Veneers and Bonding. Sometimes, it is difficult or impossible to exactly match the color of artificial teeth or restorative materials with natural teeth. Although assistance will be provided by the Dentist, it is my responsibility to make changes, if any, (including, for example, shape, size, fit and color) before permanent cementation. After a temporary crown has been placed, it is essential to have the new crown cemented as soon as it is ready because the temporary crown is not intended to function as a permanent restoration. Failing to replace the temporary crown could lead to decay, gum disease, infections, problems with the bite and even loss of the tooth. Further, if there is a prolonged delay in placing the permanent crown, it may no longer properly fit. I have discussed treatment alternatives, risks, outcomes and costs with the Dentist and have had all of my questions answered before making a decision. I understand that dentistry is not an exact science and that there are no guaranteed results. Unless otherwise provided by law, I understand that I am responsible for payment of all dental fees not paid in full by any insurance or other applicable coverage. Having had adequate time to reflect upon the alternatives, I consent to the treatment, subject to changes in treatment plan, as detailed above.
Release:
I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper care.
I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist.
I hearby authorize payment of insurance benefits directly to Pierson Dental, LLC, otherwise payable to me.
I understand that my dental care insurance carrier or payor of my dental benefits may be less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be fully responsible for payment of services not paid, in whole or in part by my dental care payor. In addition. I agree to have 1.5% service charge added to my account for each of the 30 days payment is past due, excluding insurance. There will be a $30.00 No Show/Cancellation Fee for all appointments not cancelled within 48 hours.
I attest to the accuracy of the information on this page.
Patient or Guardian's Signature _________________________________________________________ Date: _______________________