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Walk In Family Dentistry
Phone:
(647) 799-6622
2365 Finch Ave W #201, North York, ON M9M 2W8, Canada
Walk-ins Welcome
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New Patients Form
Patient Forms
Cosmetic Dentistry Forms
Consent for Composite or Porcelain Veneers Form
Consent for Dental Crown Form
Bridge Prosthetics Consent Form
Crown And Bridge Form
Crown and Bridge Form Consent Form
Voluntary and Informed Consent for Final Cementation
Surgical Forms
Consent For Full Dentures And Partial Dentures Form
Consent for Maxillary Sinus Elevation Surgery
Bone Grafting Surgery Consent Form
Crown Lengthening Surgery Consent Form
Gingival Grafting Surgery Consent Form
Dental Implant Consent Form
Extraction Consent Form
New patient forms
Patient Screening Form
Information Update Form
Patient Acknowledgement Form
Financial Agreement Form
Scaling & Root Planing Consent Form
Occlusal Guard Consent Form
Root Canal Therapy Information & Consent Form
Canadian Dental Care Plan
Non-insured health benefits
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Root Canal North York
Tooth Extraction North York
Wisdom Tooth Extraction North York
Dental Cleaning North York
Restorative Dentistry
Dental Filling in North York
Dentures North York
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Cosmetic Dentistry
Dental Implants North York
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Dental Bonding North York
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Retainers in North York
Invisalign North York
Emergency Dental Care
Emergency Walk-in Dentist North York
Emergency Walk-in Dentist Etobicoke
Emergency Walk-in Dentist Downsview
Emergency Walk-in Dentist Rexdale
Emergency Walk-in Dentist Jane and Finch
Emergency Walk-in Dentist Yorkdale
Emergency Walk-in Dentist Humbermede
Who We Help
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Dental Clinic for York University
Dental Clinic for Seneca Polytechnic
Dental Clinic for Centennial College
Dental Clinic for Humber College
Dental Clinic for Niagara University
Dental Clinic for East Coast University
Seniors
Low-Income Patients
Iranian Community
About
Our Practice
Our Dentists
Dr Vida Siar
Dr. Ardeshir Ranjbari
Dr Mahvareh Akhgar-Araghi
Dental Technology
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Call
(647) 799-6622
Get Directions
2365 Finch Ave W #201, North York, ON M9M 2W8, Canada
Hours
Monday: 10 AM to 2 PM
Tuesday to Friday: 9 AM to 6 PM
Saturday: 9 AM to 3 PM
Sunday: Closed
Book Now
Emergency
Call Clinic
(647) 799-6622
Directions
North York
About
Our Practice
Our Dentists
Dr Vida Siar
Dr. Ardeshir Ranjbari
Dr Mahvareh Akhgar-Araghi
Dental Technology
Smile Gallery
Patient Info
New Patients Form
Patient Forms
Cosmetic Dentistry Forms
Consent for Composite or Porcelain Veneers Form
Consent for Dental Crown Form
Bridge Prosthetics Consent Form
Crown And Bridge Form
Crown and Bridge Form Consent Form
Voluntary and Informed Consent for Final Cementation
Surgical Forms
Consent For Full Dentures And Partial Dentures Form
Consent for Maxillary Sinus Elevation Surgery
Bone Grafting Surgery Consent Form
Crown Lengthening Surgery Consent Form
Gingival Grafting Surgery Consent Form
Dental Implant Consent Form
Extraction Consent Form
New patient forms
Patient Screening Form
Information Update Form
Patient Acknowledgement Form
Financial Agreement Form
Scaling & Root Planing Consent Form
Occlusal Guard Consent Form
Root Canal Therapy Information & Consent Form
Canadian Dental Care Plan
Non-insured health benefits
Dental Blog
Promotions
FAQs
Emergency Dental Care
Emergency Walk-in Dentist North York
Emergency Walk-in Dentist Etobicoke
Emergency Walk-in Dentist Downsview
Emergency Walk-in Dentist Rexdale
Emergency Walk-in Dentist Jane and Finch
Emergency Walk-in Dentist Yorkdale
Emergency Walk-in Dentist Humbermede
Services
Browse by Need
Routine Dental Care
General Dentistry
Dental Cleaning North York
Fix a Damaged Tooth
General Dentistry
Root Canal North York
Tooth Extraction North York
Wisdom Tooth Extraction North York
Restorative Dentistry
Dental Filling in North York
Dental Crowns North York
Replace Missing Teeth
Restorative Dentistry
Dentures North York
Dental Crowns North York
Dental Bridges North York
Cosmetic Dentistry
Dental Implants North York
Improve My Smile
Cosmetic Dentistry
Teeth Whitening North York
Dental Veneers North York
Dental Bonding North York
Smile Makeovers North York
Orthodontics
Retainers in North York
Invisalign North York
Who We Help
Student Dental Clinic
Dental Clinic for York University
Dental Clinic for Seneca Polytechnic
Dental Clinic for Centennial College
Dental Clinic for Humber College
Dental Clinic for Niagara University
Dental Clinic for East Coast University
Seniors
Low-Income Patients
Iranian Community
Contact
Call
(647) 799-6622
Get Directions
North York
Hours
Contact Page
Book an Appointment
Now Welcoming New Patients with Canadian Dental Care Plan (CDCP) Benefits.
"
*
" indicates required fields
Tooth Number
*
Patient Information
Name
*
Date
*
MM slash DD slash YYYY
CROWN AND BRIDGE CONSENT FORM
Dental crowns are restorations that cover or cap teeth, restoring them to their natural size, shape, and color. A crown not only helps with appearance, but can strengthen a tooth as well. A fixed (non-removable) bridge is designed to replace teeth that have been lost. Missing teeth may need to be replaced for appearance, or to prevent or correct bite and gum problems related to shifting or stressed teeth. Dental crowns and bridges are made of porcelain, and may or may not have an inner layer of metal, while some are made of metal alone.
As with all procedures, there are certain potential problems associated with crowns and bridges. These include, but are not limited to:
1-
The potential need for root canal therapy: The need for root canal therapy may become apparent during a crown preparation, or after a crown is made.
2-
Dark lines at the gum line may appear on crowns or fixed bridges lined with metal. This is the metal edge of the crown. Ifthe gum recedes after placement, this metal will show. Sometimes this can be corrected, other times a new crown or bridge might be recommended.
3-
Food impaction may occur under a bridge- this may be an unavoidable condition. Meticulous home care is required.
Crowns should usually be completed within one month. Failure to keep appointments (resulting in wearing the temporary crown for longer) can lead to gum disease, tooth loss, or a need to redo the crown at additional cost.
I further understand that I may be wearing temporary crowns for several weeks, which may come off and I must be careful to ensure that they are kept on until the permanent crowns are delivered.
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth.
I realize the final opportunity to make changes in my new crown (cap), or bridge, including shape, fit, size, and color will be before permanent cementation. After permanently cementing crowns and/or bridges, NO changes can be made.
I understand that like natural teeth, crowns and bridges need to be kept clean with proper oral hygiene and periodic professional cleanings, otherwise decay may develop underneath and/or around the margins of the restoration, leading to further dental treatment and possible replacement of the crown(s) and/or bridge.
All replacements due to decay will be the patient's responsibility, however, any breakage, cracks and fractures in the crown or bridge will be replaced at no charge to the patient for a period of up to two years after the initial placement of the crown(s) or bridge. With similar conditions, after two years and until five years, work will be replaced at half the current fee.
In this office all of the doctors place additional efforts to insure the longevity and quality of crowns and bridges. We want you to be happy with the treatment you receive here enough that you refer your family and friends.
Consent
*
I agree to the Consent.
Dental crowns are restorations that cover or cap teeth, restoring them to their natural size,
shape, and color. A crown not only helps with appearance, but can strengthen a tooth as
well. A fixed (non-removable) bridge is designed to replace teeth that have been lost.
Missing teeth may need to be replaced for appearance, or to prevent or correct bite and
gum problems related to shifting or stressed teeth.
Dental crowns and bridges are made of porcelain, and may or may not have an inner
layer of metal, while some are made of metal alone.
As with all procedures, there are certain potential problems associated with crowns and
bridges. These include, but are not limited to:
1-
The potential need for root canal therapy: The need for root canal therapy may
become apparent during a crown preparation, or after a crown is made.
2-
Dark lines at the gum line may appear on crowns or fixed bridges lined with
metal. This is the metal edge of the crown. Ifthe gum recedes after placement,
this metal will show. Sometimes this can be corrected, other times a new crown or
bridge might be recommended.
3-
Food impaction may occur under a bridge- this may be an unavoidable condition.
Meticulous home care is required.
Crowns should usually be completed within one month. Failure to keep appointments
(resulting in wearing the temporary crown for longer) can lead to gum disease, tooth loss,
or a need to redo the crown at additional cost.
I further understand that I may be wearing temporary crowns for several weeks, which
may come off and I must be careful to ensure that they are kept on until the permanent
crowns are delivered.
I understand that sometimes it is not possible to match the color of natural teeth exactly
with artificial teeth.
I realize the final opportunity to make changes in my new crown (cap), or bridge,
including shape, fit, size, and color will be before permanent cementation. After
permanently cementing crowns and/or bridges, NO changes can be made.
I understand that like natural teeth, crowns and bridges need to be kept clean with proper
oral hygiene and periodic professional cleanings, otherwise decay may develop
underneath and/or around the margins of the restoration, leading to further dental
treatment and possible replacement of the crown(s) and/or bridge.
All replacements due to decay will be the patient's responsibility, however, any
breakage, cracks and fractures in the crown or bridge will be replaced at no charge to the patient for a period of up to two years after the initial placement of the crown(s) or
bridge. With similar conditions, after two years and until five years, work will be
replaced at half the current fee.
In this office all of the doctors place additional efforts to insure the longevity and quality
of crowns and bridges. We want you to be happy with the treatment you receive here
enough that you refer your family and friends.
Signature:
*
Date
*
MM slash DD slash YYYY
Doctors Signature
*
Date
*
MM slash DD slash YYYY
Witness Signature
*
Date
*
MM slash DD slash YYYY
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