DENTAL TREATMENT CONSENT FORM

Please read and initial the items checked below

and read and sign the section at the bottom of form. Patient Name_

n 1. WORK TO BE DONE
I understand that I am having the following work done: Fillings_ Bridges_ Crowns_ Extraction
lmpacted teeth removed _ General Anesthesia Root Other
(lnitials_)
Z z. DRUGs AND MEDTcATToNS
I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of
tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). (r

I g. CHINGES tN TREATMENT PLAN

I understand that during treatment it may be neces.sary to change or add procedures because of conditions found while working on
the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative
procedures. I give my permission to the Dentist to make any/all changes and additions as necessary. (

E l. neuovAloFTEETH
Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery etc.) and I authorize the
Dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I
understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I
understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling
in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured
jaw. I understand I may need lurther treatment by a specialist or even hospitalization if complications arise during or following treatment,
the cost of which is my responsibility. (lnitials_)
E s. cnowN, BRTDGES AND cAPS
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 and that I must be careful to ensure that they are kept on until the
permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit,
size, and color) will be before cementation.

E s. oenruREs, coMPLETE oR PARTTAL

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these
appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make
changes in my new dentures (including shape, fit, size, placement, and color) will be the "teeth in wax" try-in visit. I understand that
most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in
the initial denturefee. (lnitials_)
E z. enooDoNTrc TREATMENT (Roor cANAL)
I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and
that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of
the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment
(apicoectomy). (ln

fl a. eERToDoNTAL Loss (TrssuE & BoNE)

I understand that I have a serious condition, causing gum and bone infection or loss and that it can lead to the loss of my teeth.
Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that
undertaking any dental procedures may have a future adverse effect on my periodontal condition. (r

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I
acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and
authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I
consent to the proposed treatment.

Signature of Patie Date-

SignatureofParenUGuardianifpatientisaminor Date-
#21153 @MedicalAds Press" 1'800'328 2179
 Vizi LitePR(,
ORAL LESION SCREENING SYSTEM

Adiunctive Oral Abnormalities Screening Form

Complete each time the exam is offered and place in the patient's file

Our practice continually strives to provide important enhancements in oral healthcare for our patients. We are
concerned about oral abnormalities and their relationship with serious diseases such as oral cancer. For this
reason, we offer screenings to every patient for early detection.

Oral cancer is one of the deadliest diseases we encountel and research shows that the late detection of oral
cancer is the primary reason that mortality rates are highl As is the case with most other cancers, age is a
primary risk factor for oral cancer. Tobacco use and chronic alcohol consumption are also major risk factors.

We find that using Vizilite PRO along with a visual examination improves our ability to identify suspicious
- -
areas that may have been missed during the conventional examination. Early detection of abnormalities can
minimize or eliminate the harmful and potentially disfiguring effects of serious oral diseases such as cancer, and
possibly save your life. A painless exam gives us a better chance of finding any oral abnormalities you may have
at an early stage. ln our practice, the exam will be offered to you annually.

Dental insurance may or may not cover the exam. However, our office is happy to verify your coverage for you.
We will also provide you with a medical insurance form that you may use to file this procedure with your medical
insurance provider. The fee for this exam is $

I Yes. I authorize the my dental professionalto perform the ViziLite PBO screening along with the standard oral
examination. I accept financial responsibility for this exam.

I tto. I would prefer not to have an oral abnormality screening exam at this time.

Print name:

Signature: Date:

Oral cancer risks include:'

. Tobacco use
. Chronic alcohol consumption 1-800-4DENMAT
(1-800-433-6628)
o Oral HPV 16/18 infection www.denmat.com

1 oralmcerfoundation.org/facts

O201 6 Den-Mat Holdings, LLC- All rights re*rued. 1 01 7 W Central Avenue, Lmp@, CA 93436 USA 8041 79800 1 0/1 6SN
dnDenMat'
 POST-OP INSTRUCTIONS
It is important to follow instructions after your dental treatment to ensure proper healing and
to avoid complications. As a rule of thumb, you should always wait two hours after your
treatment before eating to let the anesthesia wear off. Trying to eat before this could result in
soft tissue damage because you are not able to feel all of your mouth. The instructions found
below are guidelines. After your treatment the doctor or dental assistant will give you full
instructions on how to properly recover.

White Fillings (Bonding)

After the anesthesia wears off your teeth will likely be sensitive. You should avoid hot and
cold food or drink for the next few days. After that initial period, your treated teeth will feel as
good as new. Continue your normal hygiene plan to ensure that your fillings last for a long
time.

Crowns and Bridges

Before you receive your permanent crown/bridge you will first receive a temporary
restoration. This is not as sturdy as the permanent version, so you should be careful when
cleaning and eating. You should brush the area gently and should not pull up on the tooth
when flossing because it could become dislodged. The same goes for eating. You should avoid
sticky or chewy foods while you have the temporary in.

There may be some sensitivity and irritation after the temporary or permanent is placed. This
is normal and will subside after the soft tissue heals. A warm salt water rinse will help, and
you can also take Advil or Tylenol if the pain does not go away.

When the permanent crown or bridge is placed it may feel a little awkward for a few days.
Your mouth needs to adjust to the new tooth, and it should feel like one of your natural tooth
in less than a week. If your bite feels abnormal in any way, you should let your dentist know.
Caring for your bridge or crown is just like caring for your own teeth. You should brush and
floss regularly.

Scaling and Root Planing

After this procedure your gums will probably be slightly sore and irritated for a few days. You
should rinse your mouth with warm salt water (1 tsp salt/8 oz water) 2-3 times a day. This
will relieve the pain and cleanse the area. Brushing and flossing should be continued right
after the procedure, but you should brush gently so that you do not further irritate the area. If
you experience any swelling or stiffness in the area you can place a cold compress on the area
and take some pain relieving medicine. Avoid any hard or chewy foods for 2-3 days after the
surgery to ensure the area heals correctly. If you continue to experience pain or swelling after
a few days contact your dentist.

Veneers

Before you receive your permanent veneer you will first receive a temporary restoration. This
is not as sturdy as the permanent version, so you should be careful when cleaning and eating.
You should brush the area gently and should not pull up on the tooth when flossing because it
could become dislodged. The same goes for eating. You should avoid sticky or chewy foods
while you have the temporary in.

There may be some sensitivity and irritation after the temporary or permanent is placed. This
is normal and will subside after the soft tissue heals. A warm salt water rinse will help, and
you can also take Advil or Tylenol if the pain does not go away.

When the veneer is placed it may feel a little awkward for a few days. Your mouth needs to
adjust to the new tooth, and it should feel like one of your natural tooth in less than a week. If
your bite feels abnormal in any way, you should let your dentist know. When brushing and
flossing you should pay close attention to the area between the veneer and the tooth at the
gum line.

Root Canal Therapy

You can expect soreness after a root canal procedure for a few days. You should avoid chewing
on the side of your mouth where the procedure was performed so you do not irritate the area
and also to ensure that the temporary restorative material properly sets. You will also need to
take an antibiotic to treat any remaining infection in your tooth. If you notice an increasing
amount of pain or tenderness, a reaction to the medication, or the loss of the temporary
restoration (filling) call your dentist immediately.

Extractions

After the surgery you will need to rest. You need to be driven home by a friend or family
member because of the anesthesia. You can expect for the extraction site to bleed for a little
while after the surgery. Gauze will be applied at the completion of the surgery, and you will
need to change it when it becomes soaked. If bleeding continues for longer than 24 hours you
should call your dentist. Rest when you return home, but do not lie flat. This could prolong the
bleeding. Prop your head up on a pillow when lying down. Your dentist will prescribe you pain
medication, so if you become sore take as directed. You can also use an ice pack for the pain.
Your dentist might also provide you with a cleaning solution to clean the extraction site.

You will be limited to soft foods for a few days after your surgery. Some recommended foods
are:

• Gelatin
• Pudding
• Yogurt
• Mashed Potatoes
• Ice Cream
• Thin Soups
• ...and other food you can eat without chewing.

When drinking, make sure you do not use a straw. The sucking motion can loosen your
sutures and slow the clotting process. The same goes for smoking. If you have prolonged pain,
bleeding, irritation, or don't feel that the extraction site is healing properly call your dentist
for a follow up.