Crown and Bridge Prosthetic Consent I UNDERSTAND that treatment of dental conditions requiring CROWNS and BRIDGES include certain risks and possible unsuccessful results, which may cause failure. I agree to assume those risks, possible unsuccessful results and or failure. (There is no promise or guarantees of anticipated results or longevity of the treatment.) Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth it is necessary to modify the existing tooth or teeth so that crowns (caps) and bridges may be placed upon them. Tooth preparation will be done as conservatively as possible. In preparation of teeth, anesthetics are usually needed. At times there may be swelling, jaw muscle tenderness or even a resultant numbness of the tongue lips, teeth, jaw and facial tissues which is usually temporary or rarely permanent. Sensitivity of teeth: Often, after the preparation of teeth for crowns or bridges the teeth may exhibit sensitivity. It may be mild to severe. This sensitivity may last only for a short period of time or may last for much longer. If it is persistent, notify us. Crowned or Bridged abutment teeth may require root canal treatment: Teeth after being crowned may develop condition known as pulpits or pulpal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation or other causes. It is necessary to do a root canal treatment in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. The tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possible extraction. Breakage: Crowns and bridges may possibly chip or break. Many factors could contribute to this situation such as chewing excessively hard materials, changes in biting forces, traumatic blows to the mouth etc. Unobservable cracks may develop in crowns from these causes, but the crowns/bridges may not actually break until chewing soft foods or possible for no apparent reason. Breaking or chipping seldom occurs due to defective material. Uncomfortable feeling: This may occur because of the differences between natural teeth and the artificial replacement. Most patients become accustomed to this feeling. In limited situations, muscle soreness or tenderness of the jaw joints may appear for a period of time. Appearance: Patients will be given the opportunity to observe the appearance of the crowns or bridges in place prior to final cementation. Longevity of crowns and Bridges: There are many factors that determine “how long” crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. Additionally, general health, good oral hygiene, regular dental checkups, diet etc... can affect longevity. Because of this, no guarantees can be made or assumed to be made. It is the patient’s responsibility to seek attention from the dentist should any issues or problems occur. The patient must diligently follow any and all instructions, including the scheduling and attending all appointments. Failure to keep the cementation appointment can result in ultimate failure of the crown/bridge to fit properly and additional fee may apply. Crown and Bridge Prosthetics INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of crowns and bridge treatment and have received answers to any questions I may have. I voluntarily assume any and all possible risks including those as listed above and including risk of harm, if any, which may be associated with any phase of this treatment. The fee’s for service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize Dr. and his/her associates to render any treatment necessary. I give permission for any administrating of any medications and/or anesthetics deemed necessary to my treatment.Patient's name: (please print)Signature of patient:Date: Date Format: MM slash DD slash YYYY Tooth number(s):Signature of provider:Date: Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.