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Patient Information

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voluntary and Informed Consent for Final Cementation

I, the undersigned, understand and acknowledge that treatment of dental conditions requiring crowns, veneers, and/or fixed bridges includes certain risks, the possibility of unsuccessful results, and even the possibility of failure. I agree to assume those risks, possible unsuccessful results, and potential failure associated with the cementation of my crowns, veneers, and/or bridges. I understand that the risks include, but are not limited to:

Please Initial In Agreement After Reading Each Item

1-Abscess/lnfection: Infrequently, a tooth may abscess or otherwise not heal, requiring root canal therapy, root surgery, and/or extraction.
2-Possibility of needing root canal therapy: If teeth remain sensitive for long periods of time following cementation, root canal therapy may be necessary.
3-Breakage: Restorative appliances may possibly chip or break as a result of many factors, including, but not limited to, excessive chewing of hard materials, changes in biting forces, & trauma to the mouth.
4-Discomfort/Sensitivity: Due to difference between artificial materials and natural tooth structures, it is not uncommon for patients to experience an acclimation period.
5-Dissatisfaction: Though I will be given an opportunity to observe and approve restorative appliances prior to final cementation, it is possible that I may be unhappy with the final result. I accept responsibility for the full replacement cost should I desire one.

This certification must be signed by the patient or patient's legal guardian if not yet 18 years old.

I have been given the opportunity to ask any questions regarding the nature and purpose of crown/veneer/bridge treatment and have received answers to my satisfaction. I have had the opportunity to view my crown(s), veneers, and/or bridge(s) as processed, either on models or in my mouth. I approve the color, shape, feel, overall appearance, and condition of the product. I understand that once the appliance is cemented in my mouth, the factors of color, shape, feel, appearance. and condition cannot be changed without additional and possibly significant time being taken and fees assessed. I further understand that if I authorize cementation and later decide I do not like the restoration(s), I will accept the full cost for the replacements. I voluntarily assume any and all potential risks, including those listed above as well as the risk of substantial harm, which may be associated with any phase of this treatment in hopes ofobtaining the desired results, which may or may not be achieved. The cost for services have been explained to me and are satisfactory. No guarantees have been made to me in regards to the results I am striving to achieve and I hereby release Gentle Dental Family Dentistry from the liability of my potential dissatisfaction with the outcome. I certify that I have read and fully understand the terms, words and explanations made in above. I give my free, voluntary, and informed consent and permission for the cementation.
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