Consent to Perform Dentistry
I hereby authorize the Dentist(s) of University Dental Care, P.C. and/or dental auxiliaries of his/her choice, to perform any of the following dental treatments or oral surgery procedures including the use of necessary local anesthesia, radiographs, or other diagnostic aides.
Preventative hygiene treatment (prophylaxis) and the application of topical fluoride
Application of sealants to the grooves of the occlusal surface of back teeth
Treatment of disease or injured teeth with dental restorations (fillings and/or crowns)
Replacement of missing teeth with dental prostheses (bridges, partial dentures, full dentures)
Removal (extraction) of one or more teeth
Treatment of diseased or injured oral tissues (hard or soft)
Treatment of malposed (crooked) teeth and/or oral development or abnormal growths
Suggest use of sedative drugs to control apprehension or disruptive behavior
I understand that there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me and that I will have the opportunity to ask questions regarding the treatment and risks until I fully understand.
I agree to the use of local anesthesia.
I recognize that during the course of treatment, unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize any additional procedures that are deemed necessary or desirable to my oral health and well-being in the professional judgment of the dentist.
There are possible risks and complications associated with the administration of local anesthesia and sedative drugs. The most common of these are: swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips; gums; face; and tongue and allergic reactions, hematoma (swelling or bleeding near the injection site), fainting, and lip and cheek biting resulting in the ulceration and infection of the mucosa. I also understand that there are rare potential risks, such as unfavorable reactions to medication such as respiratory and cardiovascular collapse (stopping of breathing) and lack of oxygen to the brain that could result in coma or death. I acknowledge that I have been informed of the above risks and complications.
I also authorize the doctors to use photographs, radiographs, or other diagnostic materials and treatment records for the purpose of teaching, research, and scientific publications.
I will be advised that the success of my dental treatment will be dependent on my compliance with post-operative and post-care instructions to be followed and by maintaining regular office visits as scheduled by my dentist and his/her auxiliaries.
I hereby state that I have read and understand the above and understand that all questions about the procedures will be answered in a satisfactory manner. I understand that I am responsible for providing answers to questions that may arise during or after the course of my treatment.
I further understand that this consent will remain effective until such time that I choose to terminate.