CONSENT FORM FOR OCCLUSAL GUARD - Walk In Family Dental

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INFORMED CONSENT FOR OCCLUSAL GUARD

Patient Name*

Date*

I voluntarily consent to the fabrication of an Occlusal Guard.

The type of guard suggested for my current condition is:

type of guard*

I understand that an occlusal guard may minimize the possible harmful effects of occlusal habits including: sensitive teeth, worn teeth, cracked or fractured teeth. I also understand that the occlusal guard will not prevent my occlusal habits from continuing but rather introduce a protective material between my upper and lower teeth to minimize additional damage or symptoms of occlusal stress. It is only effective while it is being worn and provides no protection during times when it is not worn.

I have been informed that the symptoms I may currently have may be the result ofocclusal habits. There may be other dental and systemic conditions that may be contributing to my symptoms. Further evaluation for other causes may be necessary.

I fully understand that an occlusal guard or splint of a more sophisticated design may be necessary in the future depending on my response and the durability of the material over time with my particular occlusal habits.

I have been informed that my condition can sometimes be treated simply over the short term or could require treatment over several years and could include orthodontic treatment, restoration with crowns, bridges, implants or surgery.

I have had an opportunity to ask questions and am fully satisfied with the answers I have received.

Longevity/replacement. The occlusal guard will/may require replacement if it is lost, damaged, worn or the underlying teeth are changed (with new fillings, crowns, bridge, etc.). Additional fees will apply if replacement is necessary.

Patient Signature*

Date*
MM slash DD slash YYYY

Dentist Signature*