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Consent for Crowns & Bridges

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First name

Last name

If you have any questions, please ask your doctor BEFORE signing. You have the right to be informed about your diagnosis and planned procedure so that you can decide whether to have a procedure or not after knowing the risks, benefits and alternative options.

Your diagnosis is

Caries

Broken Tooth

Root Canalled Tooth

Alternative treatment methods include

Extraction

Filling

None

Your planned treatment is crown/bridge on teeth

Oral Hygiene: I understand that good oral hygiene is essential to prevent decay and to assist in the successful treatment of dental conditions.

Drugs and Medications: I understand that antibiotics, pain medications, anesthetics and other medications can cause allergic reactions, resulting in redness and swelling of tissues, itching, pain, nausea and vomiting or more severe allergic reactions. I have told the doctor of any known allergies. I know it is important to take any medicines that are prescribed for me as directed to help minimize potential problems. Certain medications may cause drowsiness and I should not drive or operate hazardous equipment when using such drugs. If I have a problem, I should get appropriate medical care from either my doctor or in emergencies by calling 911.

Crowns and Bridges: I understand that it is sometimes not possible to exactly match the color of natural teeth with artificial teeth. I further understand that I may be wearing temporary crowns that are prone to loosening and may need re-cementing. I will notify my doctor if that happens so that a temporary restoration is maintained until the final restoration is delivered. I realize that any changes in the color, shape, size, etc. of a crown I may want must be made prior to final fabrication of the restoration. It is my responsibility to return for tooth preparation and final cementation of the restoration as directed by my doctor. If the crown or bridge becomes dislodged at any time, I need to call the doctor. I understand I may need further treatment by a specialist if complications arise during treatment, and I am responsible for paying any of those costs.

Changes in Treatment Plan: I understand that it may be necessary during treatment to change or add procedures because of conditions discovered during treatment that were not evident during examination. If so, I will be advised by my doctor. I understand that my doctor can’t promise that everything will be perfect. I understand that the treatment listed above and other forms of treatment or no treatment at all are choices I have. I have read and understand the above and give my consent to have the recommended treatment. I have given a complete and truthful medical history, including all medicines, drug use, pregnancy, etc. I certify that I speak, read and write English. All of my questions have been answered before signing this form.

*I have read, understood, and agree to the above Oral Hygiene, Drugs and Medication, Crowns and Bridges, and Changes in Treatment Plan consents.

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📩 Your consent form has been received!

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