Consent Form
This form you are being asked to sign is a confirmation that we will discuss the nature and the purpose of dental treatment, the known risks that are associated with dental treatment, and the feasible treatment alternatives. You will be given an opportunity to ask questions and all
your questions will be answered in a satisfactory manner to your understanding.
1. It is my responsibility to understand that the practice of dentistry is not an exact science. There are no guarantees or assurances as to the outcome of treatment. understand that unforeseen conditions or circumstances may arise during the course of treatment and that additional treatment and associated costs may occur.
2. I understand that the estimate given to me is for normal and usual treatment. understand that if my treatment requires extra time, additional procedures or additional laboratory work, there will be additional fees related to that.
3. After thoroughly examining my teeth, gums, cheeks, lips, tongue and throat, Dr. Ajay Goyal & Associates will present to me a complete treatment plan. Alternatives to the treatment recommended will be explained and offered.
4. I will be informed of the possible risks and complications involved with surgery, dr ugsand anaesthesia. Situations include but are not limited to: pain, sensitivity, infection,discolouration, inflammation of a vein, and the exact duration may not be determinableand may be irreversible. Dr. Ajay Goyal & Associates will inform me of the possible risksand complications that may be involved with dental treatment. These include but are not limited to: root canal therapy, fracture of teeth or roots, fractures of porcelain or acrylic,loss of crowns, restorations, and possibly teeth. I understand that should any of these conditions arise they may necessitate further treatment.
5. I understand that if the recommended treatment is not pursued, any of the following may occur: Loss of teeth, loss of bone, gum tissue inflammation, infection, decay,sensitivity, looseness of teeth (followed by the need for extraction), fracture of teeth hand/or root, difficulties in chewing and/or speech. Also possible are temporomandibularjoint (TMJ) problems, headaches, and referred pains to the back of the neck and facial muscles when chewing.
6. I understand that there is no method to accurately predict the outcome of dental treatment due to large variations in teeth, gums, bone, chewing forces, and oral hygiene. I also understand that in some instances dental treatment may not be successful.I agree to follow all of the home care instructions that will be provided to me by my hygienist or Dr. Ajay Goyal & Associates. I agree to report to my dentist for regular examinations as indicated and I understand that this office will monitor my progress.
7. To my knowledge I will give an accurate report of my physical and mental health history. I have also reported any prior allergic reactions to drugs, food, insect bites,anesthetics, pollen's, dust, any blood or body disease, gum or skin reactions, abnormal bleeding or any other condition related to my health.
8. I understand that my teeth, gums or bone can be damaged by bacteria and I must do my utmost to remove the bacterial plaque off all the surfaces or all my teeth and/or implant servery day. If I do not clean my teeth and/or implants properly, I may get decay and/ or gum disease and my treatment may fail.
9. I consent to the use of photography, study models, and x-rays of the area being treated for the purpose of teaching dentistry. I understand that my insurance is my responsibility,and not the responsibility of the office. I am responsible to know my insurance limits. I am solely responsible for all costs that occur.
10. I agree to the use and disclosure of my personal information to insurance companies and dental specialty offices to which I've been referred.
I am aware that I will be fully informed of treatment and any potential risks involved before any treatment is initiated.
By signing this form I agree to receiving dental treatment by Dr. Ajay Goyal and Associates.
Patient/Parent/Guardian Signature:
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