Consent Forms Your DetailsName* MrMrsMissMsDrProf.Rev. Prefix First Last Email*To receive a copy of this form please enter your email Enter Email Confirm Email DOBDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Consent Form Type* Oral Surgery/Tooth Extraction Informed Consent Post Operative Advice Periodontal Disease Informed Consent Statement Home Whitening Instruction and Consent Form Patient’s Informed Consent for Whitening Root Canal Treatment Consent Oral Surgery/Tooth Extraction Informed ConsentI understand that there may be alternatives to the extraction of teeth and after the dentist’s explanation, I have chosen extraction. There are various normal complications that can occur despite all efforts to the contrary as a result of the extraction(s) which include but are not limited to: Bleeding, bruising, and swelling: Post-operatively I can expect some pain, swelling, discolouration of the face, and/or bleeding. Swelling may occur for several days after surgery. Recuperation may require several days at home.Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anaesthetics or other medications administered or prescribed. All prescription drugs must be taken according to instructions. Women using contraceptive medication must be aware that antibiotics that may be necessary to control infection can render these contraceptives ineffective. Other methods of contraception must be utilized during the treatment period.Injury to the nerves: This would include injuries causing numbness of the lips; the tongue; any tissues of the mouth; and/or cheeks or face. This numbness could occur and may be of a temporary nature, lasting a few days, a few weeks; a few months; or could possibly be permanent and could be the result of surgical procedures or anaesthetic administration.A dry socket: (Poor healing of the socket) may occur. A dry socket is painful and requires frequent treatment.Root tips sometimes break off in the bone and may be left to avoid extensive surgery. With upper teeth, the root tips sometimes expose or are pushed into the maxillary sinus.Infection: No matter how carefully surgical sterility is maintained, it is possible, due to an existing non-sterile or infected oral environment, infections may occur post operatively.Injury to adjacent teeth/filling or adjacent roots: There is a possibility of injury to an adjacent tooth/filling or to roots of teeth during the procedure. If an adjacent tooth or roots of teeth are inadvertently nicked or otherwise damaged during the surgical procedures, conventional endodontic treatment, endodontic surgery, or extraction may be required.Temporomandibular joint dysfunction (the jaw joint may not function well) may occur.I was given the option of different anaesthetic techniques, and I consent for the local anaesthesia to be used. The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I have read and understand the above and have had all my questions answered to my satisfaction and I agree to proceed with the recommended extraction(s). I was given the option of different anaesthetic techniques, and I consent for the local anaesthesia to be used. The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I have read and understand the above and have had all my questions answered to my satisfaction and I agree to proceed with the recommended extraction(s).Signature*Signature of patient; patient’s guardian or authorised person.Date of SignatureWitness Signature*Date of SignaturePost Operative AdviceProtocol following Oral Surgery/Tooth extraction After the tooth is extracted the socket left behind fills with blood which clots and heals over. DO NOT DISTURB THE BLOOD CLOT. You may feel a sharp edge at the socket and small fragments may work loose. This is normal.Follow your dentist’s instructions regarding any gauze packs placed at the end of your visit. Your dentist will provide spare packs should bleeding continue. Apply biting pressure for 20-30 minutes, whilst resting in an upright position. Rest is very important as it reduces the blood pressure.Take any painkillers that have been advised by your dentist. Ibuprofen or paracetamol are usually sufficient. Avoid aspirin as it may cause bleeding to continue.DO NOT RINSE today as this can disturb initial healing. After today, rinse your mouth with a cup of warm water with a half a teaspoon of salt diluted in it or antiseptic mouthwash, three times a day for the next 2 weeks. This will help to keep the socket clean and flush out trapped food.Tonight rest with your head above the level of your feet, using an extra pillow if needed.Do not consume alcoholic drinks and avoid strenuous activities for the next 48 hours. Avoid smoking for the next week as it can delay healing and increase the chance of infection.Follow a soft diet today. Avoid chewing in the area of the extraction for at least 3 days. Drinks such as warm tea are fine, but drink them straight back and do not swill them around the socket.You may clean your teeth as normal. You may experience some swelling or discomfort for a few days after the procedure. This is normal.As with any surgery there is a small risk that the pain may persist or worsen. If you have severe pain, swelling occurs or the bleeding persists then please call us. We may then need to prescribe antibiotics. Signature*Date of SignaturePeriodontal Disease Informed Consent StatementPatient's Treatment Choice: I have been advised that I have periodontal disease. Please read the following information carefully Please take the time you need to ask all your questions before you sign. During periodontal charting and examination you were found to have gum pocket depths of 4-6mm or more. Anything greater than 3mm, with bleeding, is considered a disease condition. These pockets develop as a result of a bacterial infection of the gum tissue. The deeper the pocket, the more destruction that has occurred. This infection leads to loss of bone, and eventually tooth loss. There are also many correlations with other systemic disorders such as heart disease, diabetes, and complications with pregnancy. Lack of treatment and good home therapy can lead to more advanced gum disease with permanent loss of bone and eventually tooth loss. There is no cure for periodontal disease. We can only control the condition. We recommend a complete diagnosis and treatment planning for this condition to treat this progressive disease. I accept the recommended referral.* I accept the recommended referral.*Signature of Patient*Date of SignatureI decline the recommended referral at this time, and I understand that a routine cleaning may not improve this condition.* I decline the recommended referral at this time, and I understand that a routine cleaning may not improve this condition.*Signature of Patient*Date of SignatureHome Whitening Instruction and Consent FormWe are planning to whiten your teeth using a hydrogen peroxide gel. Please read the following instructions carefully. The active ingredient is hydrogen peroxide in a glycerine base. If you know of any allergy or are aware of an adverse reaction to this ingredient, please do not proceed with this treatment.As with any treatment, there are benefits and risks. The benefit is that teeth can be whitened fairly quickly in a simple manner. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to whiten teeth is safe. There is new research indicating the safety for use on the soft tissues (gums, cheek, tongue, and throat). The long-term effects are as yet unknown. Although the extent of the risk is unknown, acceptance of treatment means acceptance of risk.The amount of whitening varies with the individual. Most patients achieve a change within 2 - 5 weeks. It is important to reduce the consumption of tea, coffee, red wine, berries, and curries during or after treatment for at least 1 month. Please use the toothpaste supplied with the kit to clean your teeth during treatment.It is advisable not to smoke during the course of whitening treatment and for at least 5 - 8 weeks afterward.You may notice slight sensitivity after a few days of treatment. If this should occur refrain from using the whitening treatment for 3 to 4 days.Do not use the whitening treatment if you are pregnant. There have been no adverse reactions, but long-term clinical effects are unknown.Wear the trays overnight or for one to two hours during the day (e.g. whilst watching television in the evening.It may be necessary to do a top-up treatment in 18 - 24 months depending on the amount of staining and your diet.I have read the above information and agree to return for examination in 28 days after treatment begins and at any recommended time afterward. I have read and received a copy of this information sheet. I consent to treatment and assume the risks described above.* I have read the above information and agree to return for examination in 28 days after treatment begins and at any recommended time afterward. I have read and received a copy of this information sheet. I consent to treatment and assume the risks described above.*I consent to photographs being taken. I understand that they will form part of my clinical notes.* I consent to photographs being taken. I understand that they will form part of my clinical notes.*Signature*Date of SignaturePatient’s Informed Consent for WhiteningInformed consent: I have been informed that there are no guarantees as to the amount of lightening that can be achieved with whitening treatment. Further dental treatment may be required to whiten the teeth to achieve the result I am aiming for. These options may include micro abrasion, bonding, porcelain laminate veneers, crowns or combinations of the above. I have been instructed to discontinue treatment should any problems occur. Informed consent: I have been informed that there are no guarantees as to the amount of lightening that can be achieved with whitening treatment. Further dental treatment may be required to whiten the teeth to achieve the result I am aiming for. These options may include micro abrasion, bonding, porcelain laminate veneers, crowns or combinations of the above. I have been instructed to discontinue treatment should any problems occur.Signature*Date of SignatureConsent for Root Canal TreatmentI understand that many factors contribute to the success of root treatment and not all factors can be determined in advance. This includes my resistance to infection, the bacteria causing the infection, the size, the shape and location of the canals. I understand that root canal treatment has a very high success rate, but no guarantee can be given for a perfect result. Treatment may not relieve my symptoms and treatment can occasionally fail for unexplained reasons. Risks of Root Canal Treatment Inability to completely fill the root canal.Fracture or breakage of the root or crown during or after treatment.Inadvertent separation of files or instruments within the root canal system that are unable to be retrieved.Perforation of the tooth during treatmentDamage to existing fillings, crowns or porcelain veneers.Infection may reoccur and continue, requiring further treatment or extraction.I understand that during and after treatment, I may experience some pain or discomfort, swelling, bleeding and limited mouth opening. I understand local anaesthesia will be given. I may also need antibiotics to treat any associated infections.I understand that after the root canal treatment is completed, I must have a permanent restoration placed within the next few weeks. If I fail to have the tooth restored, I risk a failure of the root canal treatment, decay, infection and or loss of the tooth.I understand that root filled molar teeth routinely require crowning. Alternative to Root Canal Treatment The most common alternatives include: Extraction – Further treatment may be required including replacement by an artificial tooth by means of a removable denture, fixed bridge or dental implant. No Treatment – If I choose no treatment, my condition may worsen and I risk further symptoms, including severe pain, infection and loss of this tooth. I acknowledge that I have provided an accurate medical history, will follow treatment recommendations and have had the opportunity about these risks in continuing with root canal treatment.* I acknowledge that I have provided an accurate medical history, will follow treatment recommendations and have had the opportunity about these risks in continuing with root canal treatment.*Patient’s Signature*Patient’s Signature (Guardian if the patient is a minor):Date of SignatureDentist Signature*Date of SignatureNameThis field is for validation purposes and should be left unchanged.
