"*" indicates required fields


You, the patient, have the right to accept or reject dental treatment recommendation by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:

  • Pain, swelling and discomfort after treatment;
  • Infection in need of medication, follow-up procedures or other treatment;
  • Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste;
  • Damage to adjacent teeth, restoration or gums;
  • Possible deterioration of your condition which may result in tooth loss;
  • The need for replacement of restorations, implants, or other appliances in the future;
  • An altered bite in need of adjustment;
  • Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist;
  • A root tip, bone fragment or a piece of dental instrument may be left in your body, and may have to be removed at a later time if symptoms develop;
  • Jaw fracture;
  • If upper teeth are treated, there is a chance of sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment;
  • Allergic reaction to anesthetic or medication;
  • Need for follow-up care and treatment, including surgery.

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre- and post-treatment instructions, referrals to other dentists or specialist, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary.

The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

If you are a woman on an oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please discuss with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking, antibiotics.

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.