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Southern Dentistry

Southern Dentistry

8477-A County Road 64, Suite 3,
Daphne, AL, 36526
(251) 621-1301

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
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Primary Insurance Details( * mandatory to fill )

Primary Dental Carrier

Insurance Authorization Statement

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost and dental treatment. I hereby authorize the Dental Office to administer such medication and perform  such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

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Responsible Party's Information( * mandatory to fill )

If Patient is Under 18

Dental History( * mandatory to fill )
Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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  •  Pregnant/Trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  Metal
  •  Latex
  •  Sulfa drugs
  •  Local anesthetics
  •  Other
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status

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SOUTHERN DENTISTRY INSURANCE AND FINANCIAL POLICIES AND INFORMATION( * mandatory to fill )

We at Southern Dentistry are pleased that you have insurance benefits to help with the cost of your dental care. We would like to help you obtain the maximum use of these benefits. As a courtesy we will file your primary insurance claims for you. With this in mind, please read the information on this form so that we can work together to ensure this benefit.

ACCEPTING YOUR INSURANCE AND WHAT THEY WILL PAY

We currently accept many major insurance plans. Although we can maintain computerized histories of payment by a given company, they do change. Therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE .  If you would like to know your exact benefit we will be happy to file a pre-treatment estimate with your insurance company prior to treatment.  This does delay treatment but will give you the exact out of pocket figures you may require.

WHY YOU MAY RECEIVE A STATEMENT

We base the patient portion of your bill on our most current data, but there are many factors that can affect your estimate quoted. There may be outstanding claims from another office or even changes in the way your insurance company pays. We will always work with you to find out why your insurance company didn't pay as expected.

WHY YOUR INSURANCE MAY NOT PAY AND YOUR RESPONSIBILITY

We will bill your insurance as a courtesy . If, for any reason, your insurance company refuses to pay, you are responsible for the remaining balance . IT IS IMPORTANT TO REMEMBER THAT YOUR INSURANCE PLAN IS A CONTRACT BETWEEN YOU AND THEM.  OUR OFFICE IS NOT AND CANNOT  BE A PART OF THAT LEGAL CONTRACT . ULTIMATELY YOU ARE RESPONSIBLE FOR ALL CHARGES INCURRED AT OUR OFFICE.

FINANCIAL OPTIONS

Southern Dentistry does request payment in full for your estimated portion at the time of service. We accept cash, check, Mastercard, VISA, American Express, and Discover . If you are in need of an extended financial option we also work with Care Credit. Care Credit offers "same as cash" loan options designed to meet your financial and treatment needs. Please ask any of our staff members for more information or an application.

AMALGAM  DOWNGRADES

Due to health and cosmetic concerns, we do not do silver fillings in our office . Some insurance companies have decided to downgrade the fee for a white filling to that of a silver filling.  If this is true for your insurance company, they will make you responsible for the difference between the two. As a courtesy, we have used the information that your insurance company has provided to create an estimate of what your financial responsibility will be for this procedure.

PAST DUE BALANCES

Balances that are greater than 4 months old may be subject to an 8% monthly finance charge.

 

MISSED APPOINTMENTS

If you are unable to keep your appointment, then we ask that you give us at least 24 hours notice. If we do not receive proper notice, then you will be charged a $45 cancellation/no show fee .

We welcome you to our family and look forward to helping you achieve the healthy, beautiful smile you want and deserve.  If there is anything we can do to make your visits more pleasant, please do not hesitate to tell one of our staff members.


I have read and understand and accept the terms of the above outlined policies for insurance handling and financial commitments that I may incur as a result of treatment at Southern Dentistry

 

 

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

*You May Refuse To Sign This Acknowledgement*

have received a copy of this office's Notice of Privacy Practices.

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AUTHORIZATION  TO RELEASE/DISCUSS  INFORMATION

 

Southern Dentistry has the authority to discuss health and dental information regarding patient named

with the following individuals.

AUTHORIZATION TO TREAT PATIENT( * mandatory to fill )

I authorize the staff of Southern Dentistry to perform such treatments that are necessary to maintain optimal oral health. I understand that details regarding individual treatments will be discussed with me and that I will have the opportunity to ask questions until I sufficiently understand the treatment prescribed.

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TREATMENT OF MINORS

Complete if patient is under 14 years of age

In case parent or guardian cannot be present, the following individuals have authority to make treatment decisions for this minor. This includes permitting treatment as previously planned, and also listening to suggestions of doctor and changing previously recommended treatment.


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CONSENT FOR ENDODONTIC (ROOT CANAL) TREATMENT( * mandatory to fill )
  •  possibility of separated instruments which may prevent successful treatment
  •  perforations (accidental openings) of the crown or root of the tooth
  •  identification of crown or root fracture during or after treatment
  •  damage to existing crowns, bridges , or other appliances
  •  root canal filling material wh ich extends beyond the end or the root
  •  blocked root canals which may prevent successful treatment
  •  loss of tooth structure/weakening of tooth
  •  post-operative pain , swelling, and /or infection
  •  a 5-10% chance of failure
  •  other

The benefits of successful root canal treatment  include the relief of pain and the ability to retain the tooth  in comfort and  function .

  •  No treatment
  •  Extractions
  •  Other

I  understand  that during treatment , complications may  arise which complicate or make  treatment more difficult, or which may require additional dental  surgery.

I  understand  that root canal treatment weakens the crown of the tooth.  The dentist has explained to me the need for a restoration which adequately protects the tooth after root canal treatment has been  completed.   I  understand  that no guarantee of success has been  or can  be given.  All of my questions   have been  answered  by the dentist and  I  fully understand  all  the above statements contained  in  this consent  form.

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Informed Consent For Oral and Maxillofacial Surgery( * mandatory to fill )

Alternatives to Surgery: Risks to my health if the above procedure is not performed include but are not limited to

Infection;
Cyst or tumor formation;
Periodontal (gum) disease; and
Increased risk for complications if removal is required at a later time.

Possible Complications which have been discussed with me include but are not limited to:

1.Injury to the nerves, to the lower lip, and tongue causing numbness which could be permanent;
2.Bleeding and/or bruising which may be prolonged;
3.Dry socket;
4.Involvement of the sinus above the upper teeth;
5.Infection;
6.Decision to leave a small piece of root in the jaw when its removal would require extensive surgery and increased risk of complications;
7.Injury to adjacent teeth or fillings; and
8.Unusual reaction to medications given or prescribed. Additionally:

 

I understand that a perfect result cannot be guaranteed.  If any unforeseen conditions arise during the procedure, I request and authorize the doctor to do whatever he deems advisable to correct the condition.

I agree to cooperate completely with Dr. Nebrig and will follow post-operating instructions to the best of my ability for my own comfort and safety.  I have had the opportunity to ask questions concerning these procedures .

Optimum Dental Wellness Plan( * mandatory to fill )

Terms and Conditions

The Optimum Dental Wellness Plan is not insurance.  It only provides discounts on a variety of your dental needs.  It's a special program offered by Southern Dentistry that helps individuals and their families save on dental care. Not all dental services are covered. The plan covers regular cleanings (Type I on the Healthy Gums Program).  If more than a regular cleaning is needed, such as periodontal treatment (Type II - V on the Healthy Gums Program), the patient is responsible for the cost which is 25% off regular office fees.

This is a 6 month contract. After 6 months, your Wellness Plan Benefits must be renewed or your respective plan membership will be automatically terminated.

The office fee schedule is subject to change. The 25% off includes all treatment cost, but does not include special prices on bleaching, snore appliances, or any other special offer price. Also not included are retail items such as power toothbrushes, Clinpro toothpaste , MI Paste, etc., and cosmetic lab fees that may be applied for the use of specialty cosmetic labs. If you are referred to a specialist, you are subject to their fee schedule.

I have read the terms and conditions and I understand them to the full extent. I have been given the opportunity to ask questions. By signing below, I agree to the 6 month Optimum Dental Wellness Plan.

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Patient Agreement and Informed Consent for Cosmetically Focused Tooth Alignment( * mandatory to fill )

This  Patient  Agreement  contains  important   information   about   your   treatment.   BY SIGNING THIS PATIENT AGREEMENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. Please read carefully and ask questions about any areas that are unclear:

Scope of Treatment: Our objective is to straighten your teeth, usually without significant bite change, in a reasonable time frame-usually 4-9 months. You may  have aspects of your bite that will not be addressed with this treatment, such as, but not limited to, molar relationships/posterior cross bite, overjet, underjet, facial profile, TMJ problems, displaced tooth roots and midline discrepancies. Full correction of the items mentioned here can oftentimes involve years of orthodontic treatment. The goal of  this cosmetically focused and short-term orthodontic treatment is to correct your  chief  cosmetic  complaints, which you have shared with us. This treatment is not a replacement for  traditional comprehensive orthodontic treatment. This  cosmetically  focused  treatment  is  an alternative for people who  are  not  interested  in  traditional  comprehensive  orthodontic treatment and are seeking  a  more  cosmetically  focused  orthodontic  treatment  option that can be provided over a shorter period of time.

Hygiene: BRUSH YOUR TEETH, GUMS. braces and wires thoroughly after each meal and before going to bed. Poor oral hygiene  can  result  in   puffy.  bleeding  gums  and permanent white spots on teeth. INFLAMMATION AND BLEEDING GUMS WILL DELAY YOUR TREATMENT. An interproximal brush is the best way to clean around your braces and can be purchased in any grocery store/drug store . Use this brush between your teeth at the gumline. We do reserve the right to suspend or delay  treatment  if  your  oral hygiene is poor. Keep your  teeth and  braces clean!

Hard Food: DO NOT EAT hard food such as popcorn, ice, caramels or hard candy. These foods can break the brackets. CUT UP foods such as meats, apples, carrots etc. before eating them . (If abuse is noted on multiple periodic treatment visits, a fee of can be assessed .)

Soreness: After the braces are put on the teeth may  be sore,  usually  for  2-4 weeks. Aspirin , Advil or Aleve may be taken to relieve this . If the soreness prohibits eating even soft food. please phone for an appointment so any  necessary  adjustments  may  be made. If the inside of the lips are sore. the wax that is provided can be used as a cushion over the braces until the lips become accustomed. Taking pain medication prior to your adjustment  appointments  can  help  minimize  discomfort.

Jaw Joint: There are some patients who will develop a popping/clicking or other problems in their jaw joint during or after orthodontic treatmenl. This is very rare. Usually, orthodontic treatment provides a positive effect on the jaw joint . You should understand that pre-existing joint conditions can manifest as a popping or clicking after orthodontic treatment but orthodontic treatment by itself has not been shown to cause popping/clicking of the jaw joints.

 

Main Objective: I understand that the main objective of my orthodontic treatment is to align my teeth for cosmetic reasons. My bite and the relationship of my back teeth are not the focus of this treatment. 3-6 months may be required after treatment for the bite to settle and be completely comfortable . Significant changes in lip profile necessitate jaw surgery, which I am not seeking. I am aware of these objectives and limitations of short-term treatment. I fully understand that my course of treatment may not result in complete orthodontic correction. This is not mainstream orthodontic  treatment philosophy and many orthodontists will disagree with this type of orthodontic treatment that does not aim to completely correct/change the bite relationship.

A Cephalometric X -ray will not be taken: A cephalometric x-ray is usually taken in association with traditional comprehensive orthodontics. This type of x-ray shows the relationship of the skull, skeleton and teeth . This type of x-ray does not provide us wi th essential information for performing cosmetic  tooth  alignment.  Therefore,  a cephalometric x-ray is not  typically taken  in association with  cosmetic  tooth  alignment. By signing this consent form, you ore communicating  that you understand that this type of x-ray will not be part of your  pre-treatment  records.  If  you  desire  more  information about this topic, please ask the doctor.

Technique: Space will be made by enamel reproximotion (minor tooth  reduction) . This allows limited tooth movement in the area of the crowding. Rarely sensitivity is possible from this, but is transient and not common. Alternative treatment options to enamel reproximotion for making space include tooth extrac tion, which we only  perform  in extreme cases of crowding, and expanding the dental arch is proven  to  be  unstable  in adult patients. Upper and lower dental midlines will not be  made to  coincide  for  most cases as midline changes often require years  of  treatment.  Misshaped  and abnormally long teeth will be reshaped as part of  treatment.  On occasion,  bonding may be needed to provide an even appearance of the  edges  of  front  teeth  whether  because  of stubborn tooth movement  or  misshaped  teeth.  Charges  for  bonding will  be determined on a case-by-case  basis.

Standard of Straightness: We seek to straighten teeth to a very high level with cosmetically focused orthodontic treatment. If , however,  numerous custom requests arise which the doctor feels will take an inordinate amount of extra time or in fact may not even be possible to achieve, we reserve the right to refer you to an orthodontic specialist for conventional comprehensive, 2 year, bite-changing orthodontic treatment, without a refund of monies paid up until that point in treatment.

Retention: Teeth have a tendency to rebound to their original positions after orthodontic treatment. Very severe problems have a higher tendency to relapse, and the most common type of relapse occurs with twisted teeth. Retainers will be placed immediately to minimize relapse. Full cooperation in wearing these appliances ( full time for 6 months, at night for 6 months, and every other night indefinitely) is essential and part time wear is required for years. There  is a fee to replace lost retainers. There  are both fixed and removable options for orthodontic retainers.

Disputes: Should  any  dispute  arise  regarding  fees,  treatment ,  its  outcome, or  other matters associated with treatment, I agree to seek resolution through arbitration (peer review process) in lieu of court in order to seek a speedy and fair resolution of such issues. By signing this consent form I am agreeing to handle any dispute that might arise as a result of treatment through a dental peer review process (arbitration).

Cleanings : You should have at least one professional  cleaning during your treatment. If you have an appointment for a cleaning scheduled,  keep  it!  This  is  not  required  but highly   encouraged.

Appointments: Please keep your adjustment appointments! Missed appointments can result in delayed completion. Please notify us at least 48 hours in advance should you need to reschedule since another patient may need this time slot . There can be a fee assessed for all broken appointments or short notice cancels, (__) There are some visits that are required after your braces are off (retainer checks etc .) . These visits are very important. Relapse, bite settling, and retainer or splint adjustments (or breakage) are just some of the items we wish to monitor in this stage.

Moving: If you plan on moving to another state during orthodontic treatment, it is usually advisable to complete treatment with our office . It would be difficult to change doctors during treatment.

Disclaimer and Release of Liability: I understand that the dentist who is providing my cosmetic tooth alignment is a general dentist, is not an orthodontist, and is not employed by, on agent of, affiliated with, or licensed by Six Month Smiles, LLC. Six Month Smiles provider status denotes  only that a dental professional  has  completed  the  training course offered by Six Month Smiles, LLC. that is necessary to enable him or her to begin treating patients with the Six Month Smiles system. I understand that the  certificate provided by Six Month Smiles, LLC. to my dentist attests only to my dentist's attendance at, and completion of, the Six Month Smiles training course and does not attest to, certify, or guarantee any  level of skill or expertise or  any  quality  of  performance. I understand and acknowledge that Six Month Smiles, LLC. makes no warranties or representations regarding, and does not guarantee or certify the quality of, the services provided by my dentist or any other licensed health care professional.

 

I  HAVE READ THIS PATIENT AGREEMENT AND FULLY UNDERSTAND  ITS TERMS.

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CONSENT TO BOTOX® BOTULINUM TOXIN "A" TREATMENT( * mandatory to fill )

Botox® is a neurotoxin produced by the bacterium Clostridium A. Botox® can relax the muscles on areas of the face and neck which cause wrinkles  associated  with  facial  expressions.  Treatment with  Botox can cause  your facial expression lines or wrinkles to essentially disappear . Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow' s feet  (lateral areas of the eyes) ; and c) forehead wrinkles . Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Clients may feel a slight burning sensation while  the solution is being injected. The procedure takes about 15-20 minutes and the results last 3-6 months.  With repeated treatments, the results may tend to last longer. 

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RISKS AND COMPLICATIONS

It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1 .Post treatment discomfort , swelling, redness, and bruising, 2. Double vision  3. A weakened tear duct 4. Post treatment bacterial, and/or fungal infection requiring further treatment   5. Allergic reaction  6 .  Minor temporary  droop of eyelid(s)  in approximately  2% of injections, this usually lasts 2-3 weeks  7. Occasional numbness of the forehead lasting up to 2-3 weeks , 8.Transient headache, and 9. Flu-like symptoms may occur.

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PUBLICITY  MATERIALS

I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.

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PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE

I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing) . I do not have any significant neurologic disease including but not limited to Myasthenis Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis ( A LS), Parkinson's. I do not have any allergies to the toxin ingredients, or to human albumin.

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PAYMENT
I understand that this is an "elective" cosmetic procedure and that payment is my responsibility and is expected at the time of treatment.

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RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time .

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CONSENT TO BOTOX® BOTULINUM TOXIN "A" TREATMENT( * mandatory to fill )

ALTERNATIVE PROCEDURES
Alternatives  to the procedures and options that I have volunteered for have been fully explained to me.

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RESULTS
I am aware that when small amounts of purified botulinum ("BOTOX") are injected into a muscle  it  causes weakness or paralysis of that muscle. This appears in 2 - 10 days and usually lasts 3-6 months but can be shorter or longer. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual and there are some individuals who do not respond at all. I understand that I will not be able to "frown" while the injection is effective but that this will reverse after a period of months at which time re-treatment is appropriate. I understand that I must stay in the erect posture and that I must not manipulate the area (s) of the injections for the 2 hours post-injection period.

I understand this an elective procedure and I hereby voluntarily consent to  treatment  with  Botox® injection for Facial Dynamic Wrinkles, TMJ, or Bruxism. The procedure has been fully explained to me. I have read the above and understand it. My questions have been answered satisfactorily . I accept the risks and complications of the procedure and I understand that no guarantees  are implied as to the outcome of the procedure . I also certify that if I have any changes in my medical history I will notify the office immediately. I also state that I read and write in English.

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INFORMED CONSENT FOR PHILIPS ZOOM WHITESPEED TOOTH WHITENING TREATMENT ( * mandatory to fill )

INTRODUCTION


My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as "bleaching") of my teeth. This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form . I have the right to ask questions about any procedure before agreeing to undergo the procedure.

DESCRIPTION OF THE PROCEDURE

 

Zoom  in-office tooth whitening is a procedure  designed to  lighten the color  of  my teeth using a combination of a hydrogen peroxide gel and a specially designed  visible LED light    lamp. The Zoom treatment  involves  using the  gel  and  lamp  in conjunction  with  each other to  produce  maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the Zoom lamp for four (4) 15 minute sessions.
During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e., my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to either the gel or light. I will be provided a visible LED light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment,the shade of my upper-front teeth will be assessed and recorded.

AlTERNATIVE  TREATMENTS

I understand I may decide not to have the Zoom treatment at all. However, should I decide to undergo the treatment,  I understand there  are alternative treatments for whitening  my teeth for which  my dentist can provide me additional information. These treatments include:  Whitening Toothpastes/Gels , Other  In-office Whitening Treatments , Take-Home Whitening  Kits, Porcelain Crowns , Veneers or Composites.

COST

I understand that the cost of my Zoom treatment is determined by my dentist.  I understand that my dentist   will   inform   me  if  there   are  any  other   costs  associated  with   my  Zoom   treatment.

RISKS OF CONSENT FOR TREATMENT

I understand that:

*existing issues should be treated before undergoing a whitening procedure.

*results will vary or regress due to a variety of circumstances .

*Zoom whitening treatments are not intended to lighten artificial teeth,caps, crowns, veneers or porcelain, composite or other restorative materials, and that these types of restorations may need to be replaced at my expense to match my newly whitening teeth.


*darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth.

*teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all.

*Previous orthodontic treatments may cause teeth to whiten unevenly if any resin from the treatment was not properly removed from the teeth, either due to residual resin remaining on the teeth or overpolishing upon removal.

*those with porcelain fused to metal crowns, amalgams, lingual bars or implants may feel excessive heat.

*teeth with many fillings or cavities may not lighten and are usually best treated with other non­ whitening alternatives.

*the Zoom Lamp emits visible LED light and all materials used in the isolation process, when properly used as directed, will block any exposures of soft tissues to this light.

*it is recommended that those currently treated for a serious illness or disorder (e.g. immune compromised, AIDS, etc) should consult a medical doctor before use.

*Zoom treatment is not recommended for pregnant or lactating women.

I understand that the results of my Zoom Treatment cannot be guaranteed.

I understand  that  in-office  whitening  treatments  are  considered  generally  safe  by  most  dental professionals . I understand that although my dentist has been trained in the proper use of the Zoom whitening system, the treatment is not without risk.

I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity/Pain - During the first 24 hours after Zoom treatment, some patients can experience some tooth sensitivity or pain.  This is normal and is usually mild, but it can be worse in susceptible individuals.  Normally, tooth sensitivity or pain following a Zoom treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals.  People with existing sensitivity,  recession  exposing  root  surfaces,  exposed  dentin,  untreated  caries,  cracked  teeth, abfractions , oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher  penetration of the gel into the tooth may find that those condition increase or prolong tooth sensitivity or pain after Zoom treatment.

 

Gum/Lip/Cheek Inflammation/Burn - Improper isolation during the whitening procedure may cause or result in (i) inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel or the LED light, or (ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is usually temporary and will subside in a few days, but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or LED light.

Dry/Chapped Lips - The Zoom treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor which covers the lips. This could result in dryness or chapping of the lips or cheek margins, which  can be treated by application of lip balm, petroleum jelly or Vitamin E oil.

Cavities or Leaking Fillings - Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure.  If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result.  I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing   the  Zoom  treatment .

Cervical Abrasion/Erosion - These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abras ion/ erosion exists on my teeth, these areas will be covered with dental dam prior to my  Zoom  treatment .

 

Relapse - After the Zoom treatment, it is natural for the teeth that underwent the Zoom treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the Zoom treatment . I understand that the results of the Zoom treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

The safety, efficacy, potential complications and risks of Zoom treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request . Since it is impossible to state every complication that may occur as a result of Zoom treatment, the list of complications in this form is incomplete.

The basic procedures of Zoom treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction .

 

SIGNATURES

By signing this document in the space provided I indicate that I have read this informed consent (or it has been read to me), I fully understand the entire document and the possible risks, complications and benefits that can result from the Zoom treatment, and that I give my permission for the Zoom treatment to be performed on me.

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