Consent to Cosmetic Dentistry (Smile Makeovers)

CONSENT TO COSMETIC DENTISTRY (SMILE MAKEOVERS)

Name: Date of Birth

Patient address:

STATEMENT OF TREATING DENTIST
I have explained the procedure to the patient/parent/guardian. In particular I have explained:

Proposed treatment, as outlined on the attached treatment plan

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Intended benefits:

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3) Risks associated with treatment:

In a small amount of cases root canal treatment is needed when the blood or nerve supply of the tooth (known as the pulp) is infected through decay or injury.

The life of a crown will depend on how well it is looked after. The crown itself cannot decay, but decay can start where the edge of the crown joins the tooth. It is very important to keep this area as clean as your other teeth, or decay could endanger the crown. Properly cared for crowns will last for many years.

After a smile makeover the patients bite will change, this could also affect the speech and pronunciation of certain letters. In some cases it can take several weeks to get use to these changes. Patients are encouraged to come and see the dentist as some cases may need bite adjustment otherwise patients can develop pain.

Sides affect from such treatment could be sensitivity or in some extreme cases nerve inflammation for several weeks, if the inflammation becomes permanent root filling might be required; this is NOT included in the Cost of your Cosmetic Treatment.

The life expectancy for veneers and crowns are between 8-10 years if maintained correctly.

 Natural drifting of the teeth may occur if this was to happen you may require an orthodontic retainer in the future at an additional cost.

Name: Signature:………….………………………………….. Date:......

I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments, (including no treatment) and any particular concerns of those involved.

STATEMENT OF PATIENT/PARENT/GUARDIAN

I agree to the dental treatment proposed on the attached treatment plan, which has been explained to me by the dentist named on this form.

I understand the treatment proposed and have been given a clear and full explanation of the options available to me, the risks that they may carry and the associated costs. I agree to proceed and confirm I am satisfied with the amount of information I have been given.

I understand that i will be shown the veneers before final cementation. If for whatever reason i change my mind after cementation i will have to pay 70% of the fees if I want them replaced.

I have told the dentist about any additional procedures that I do NOT wish to be carried out without having the opportunity to consider them first.

I understand that the treatment for which I give consent may alter once treatment has begun, and that additional or alternative treatment may be required. Any alterations will only be carried out if it is necessary, in my best interest and if they can be clinically justified. I will receive a full explanation and a supplemental quote.

It has been explained to me that regular dental reviews and hygiene maintenance are essential after completion of this treatment to ensure good dental health.

I consent to photographs being taken. I understand that they may be used for documentation and for illustration of my treatment.

I understand that I will be given the opportunity to see all the crowns and veneers before they are permanently cemented. At this point in the treatment I will decide whether or not I am happy with the shape, size and colour.

I understand that this agreement is between me and the dentist only.

At the initial consultation I was advised to bring along a close friend or relative on the day of the treatment. They are also able to give their opinions on the final result before permanent cementation. I also understand that once the crowns and veneers are cemented any remakes will incur a charge of at least 70% including loss.

Name ...... Signature:………….…………………………………..

Date:......

CONFIRMATION OF CONSENT BY TREATING DENTIST

I have confirmed with the patient that he/she has no further questions and wishes the procedure to go ahead.

Name (PRINT) ……………..…………… Signature:………….………..... Date ......