Full Name *
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Birthdate *
Sex * Male Female Other
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Occupation
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For Minors Only: Parent/Guardian's Name Parent/Guardian's Occupation
Previous Dentist
Last Dental Visit
Are you in good health? * Yes No
Are you under medical treatment? * Yes No If so, what is the condition being treated?
Have you ever had serious illness or surgical operation? * Yes No If so, what is the illness or operation?
Have you ever been hospitalized? * Yes No If so, when and why?
Are you taking any prescribed or non-prescribed medication? * Yes No If so, please specify?
Are you using any tobacco products? * Yes No
Do you use alcohol, cocaine or other dangerous drugs? * Yes No
Are you allergic to any of the following? Check all that apply - Local Anesthesic (ex: Lidocaine) - Penicilin/Anibiotics - Sulfa Drugs - Aspirin - Latex - Other:
Do you have or had any of the following? Check all that apply - High Blood Pressure - Low Blood Pressure - Epilepsy/Convulsion - AIDs or HIV Infection - Sexually Transmitted Disease(STDs) - Ulcers / Stomach Troubles - Fainting Seizures - Rapid Weight Loss - Radiation Therapy - Joint Replacement/Therapy - Heart Surgery - Heart Attack - Thyroid Problem - Heart Disease - Heart Mumur - Hepatitis/Liver Disease - Rheumatic Fever - Allergies/Hay Fever - Respiratory Problems - Hepatitis/Jaundice - Tuberculosis - Swollen Ankles - Kidney Disease - Diabetes - Chest Pain - Stroke - Cancer/Tumors - Anemia - Angina - Asthma - Emphysema - Bleeding Problems - Blood Disease - Head Injuries - Arthritis/Rheumatism - Other:
TREATMENT TO BE DONE: I understand and consent to have any treatment dony by the dentist after the procedure, the risks & benefits & costs have been fully explained. These treatments incuude, but are not limited x-rays, cleanings, periodotal treatments, fillings, crowns, bridges, all types of extraction, rootcanals, and/or denture, local anesthetics & surgical cases. DRUGS & MEDICATION: I understand that antibiotics, antibiotics, analgesics & other medication can cause allergic reactions like redness & swelling of tissues, pain, itching, vomiting and/or anaphylactic shock. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change/add procedures because of conditions found while working on the teeth that was not discovered during examination. For example, root canal therapy may be needed following routine restorative procedures. I give my permission to the denist to make any/all changes and additions as necessary with my responsability to pay all the costs agreed. RADIOGRAPH: I understand that an x-ray shot or a radiograph may be necessary as part of diagnostics and to come up with tentaive diacnostic of my dental problem and to make a good treatment plan, but this will not give me a 100% assurance for the accuracy of the treatment since all dental treatments are subject to unpredictable complications that later on may lead to sudden changes and additions as necessary with my responsability to all the costs agreed REMOVAL OF TEETH: I understand that alternatives to tooth removal (root canal therapy, crows & periodontal surgery, etc.) & I completely understand these alternatives, including their risk & benefits prior to authorizing the dentist to remove teeth & any other structures necessary for reasons above. I understand that removing teeth does not always remove all the infections if present & it may be necessary to have further treatment. I understand the risk involved in having teeth removed, such as pain, swelling, spread of infections, dry socket, fractured jaw, loss of feeling on the teeth, lips, tongue & surrounding tissue that can last for an indefinite period of time. I understand that I may need further treatment under a specialist if complications arise during or following treatment. CROWNS (CAPS) & BRIDGES: Preparing a tooth may irritate the nerve tissue in the center of the tooth, leaving the tooth, extra sensitive to heat & cold pressure. Treating such irritation may involve using special toothpastes, mouth rinses or root canal therapy. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily & that I must be careful to ensure that they are kept on until the permanent crowns are delivered. It is my responsability to return for permanent cementation within 20 days from tooth preparataion, as excessive days delay may allow for tooth movement, which may necessiate a remake of the crown, bridge cap. I understand there will be additional charges for remakes due to my delaying of permanent cementation, & I realize that final opportunity to make changes in my new crown, bridges, or cap (including shape, fit, size, & color) will be before permanent cementation. ENDODONTICS (ROOT CANAL): I understand there is no guarantee that a root canal treatment will save a tooth & that complications can occur from the treatment & that occasionally root canal filling material may extend through the tooth which does not necessarily effect the success of the treatment. I understand that endodontic files & drills are very fine instruments & stresses verified in their manufacture & calcifications present in teeth can cause them to break during use. I understand that referral to the endodontist for additional treatments may be necessary following any root canal treatment & I agree that I am responsible for any additional cost for treatment performed by the endodontist. I understand that a tooth may require removal in spite of all efforts to save it. PERIODONTAL DISEASE: I understand that periodontal disease is a serious condition causing gum & bone inflammation and/or loss & that can lead eventually to the loss of my teeth. I understand that the alternative treatment plans to correct periodontal disease, including gum surgery tooth extractions with or without replacement. I understand that undertaking any dental procedures may have future adverse effect on my periodontal conditions. FILLINGS: I understand that care must be exercised in chewing on fillings, specially during the first 24 hours to avoid breakage. I understand that a more extrensive filling or corwn may be required, as additional decay or fracture may become evident after initial excavation. I understand that significant sensitivity is a common, but usually temporary, after-effect of a newly place filling. I further understand that filling a tooth may irritate the nerve tissue creating sensitivity & treating such sensitivity could require root canal therapy or extractions. DENTURES: I understand that wearing dentures can be difficult. Sore spots, altered speech, & difficulty in eating are common problems. Immediate dentures (placement of denture immediately after extractions) may be painful. Immediate dentures may require considerable adjusting & several reclines. I understand that it is my responsibility to return for delivery of dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30 days, there will be additional charges. A permanent reline will be needed later, which is not included in the inital fee. I understand that all adjustment or alteration of any kind this initial period is subject to charges. I understand that dentistry is not an exact science and that no dentist can properly guarantee accurate results all the time I hereby authorize any of the doctors/dental auxiliaries to proceed with & perform the dental restoration & treatments as explained to me. I understand that these are subject to modification depending on undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of dental fees. I agree to pay any attorney's fees, collection fee, or court costs that may be incurred to satisfy any obligation to this office. All treatment were properly explained to me & any untoward circumstances that may arise during the procedure, the attending dentist will not be held liable since it is my free will, with full trust & confidence in him/her, to undergo dental treatment under his/her care.
(Initial: )
Patient/Parent/Guardian Signature Date