I hereby authorize and direct the dentists and supporting personnel of Carabelli Dental to perform the explained dental treatment(s) and/or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs, and/or other diagnostic aids. These treatments and/or procedures include, but are not limited to examinations, oral prophylaxis (cleanings), scale and root plane (SRP - deep cleaning), fluoride applications, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) procedures, implant placements, tooth removal.
I agree to use local anesthesia, the use of nitrous oxide/oxygen analgesia, IV sedation depending on the judgement of the doctors.
I understand that there are advantages, disadvantages and risks involved with dental treatment(s) and hereby acknowledge that the advantages, disadvantages and risks have been explained to me. I have had an opportunity to ask questions regarding the dental treatment(s) and the advantages, disadvantages and risks. I fully understand those advantages, disadvantages and risks and accept dental treatment(s).
The dental treatment(s) I am receiving has been explained to me. Alternate methods of treatment, if any, have also been explained to me, as have the advantages, disadvantages and risks of each. I am advised that, though good results are expected, the possibility and nature of complications cannot be accurately anticipated.
I recognize that during the course of treatment, unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorized and request the performance of any additional procedures that are deemed necessary or desirable.
I understand and have been informed that there are possible risks and complications associated with these dental treatment(s) and the administration of local anesthesia, nitrous oxide/oxygen analgesia, and/or IV sedation. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa.
I have been given the opportunity to ask questions and give my consent for proposed treatment that will be provided at Carabelli Dental.