Consent for Dental Treatment and Acknowledgement of Information
State law requires us to obtain your consent for dental treatment. Please ask us about anything you do not understand and we are ready to answer any of your questions or explain anything concerning your treatment.
Any alternatives to the recommended treatment, including no treatment, have been explained to me. In general terms the contemplated dental treatment is: ________________________________________________________
There are risks associated with any dental treatment. This includes the administration of any local or general anesthetic agent, analgesic agent to produce conscious sedation, and/or premedication prior to dental care being rendered. Some of these risk/ complications are, but not limited to the following:
Failure of wounds to heal
Injuries to adjacent teeth and/or soft tissue
Paresthesia or numbness of: tongue, mouth, face
Fracture of mandible (lower jaw) or maxilla (upper jaw)
Opening between the mouth and sinus
Incomplete removal of teeth
Loss of teeth or bone
Slough (unanticipated loss of hard or soft tissue)
Injury adjacent structures
Breakage of roots and retained fragments
Swallowing or aspiration of objects
Allergic reaction to drugs
Trismus (jaw pain or difficulty opening mouth)
Failure of treatment to accomplish its purpose
Death (in rare instances)
Additional oral surgery, hospitalization, and/or further treatment may be required in the event of any complications.
State law also requires that I specifically advise you that although rarely occurring, dental treatment or anesthetic may result in : death, brain damage, quadriplegia, loss of organ, loss of function of an organ, loss of function of face, arm, leg, and disfiguring scars.
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