Consent for Restorative Aesthetic Cosmetic Dentistry

1. I give permission for the dentist and their associates to provide additional services as they may deem reasonable and necessary, including, but not limited to:
• The administration of anaesthetic agents.
• The performance of necessary laboratory.
• Radiological (x-ray).
• Photographic.
• Other diagnostic procedures.
• Administration of medications.
2. I consent to use the procedure’s photography, filming, recording and x-rays for records/teaching/promotion purposes.
3. Unforeseen conditions can arise during treatment, which may alter the treatment plan. I authorise the Doctor and their assistants/associates to do what they deem necessary under the circumstances, including the decision not to proceed with the restorative treatment.
4. If unforeseen conditions arise, the Doctor will inform me as quickly as possible of these conditions, treatment changes, and costs.
5. The Doctor has explained alternative treatments, including their risks and benefits. I have considered these alternative treatments, but I request the chosen restorative/aesthetic/cosmetic dentistry. I declare that I have decided to go through the advised treatment.
6. I am aware that the practice of dentistry is not an exact science, and no guarantee can be made should any restoration fail.
7. I understand that I will require ongoing maintenance care, and the longevity is related to what I eat and drink and my home care habits. I understand that if I clench or grind my teeth or have other similar habits, it is more likely that I will need remakes and maintenance.
8. I declare I will wear a splint if the Doctor advises it.
9. I understand that composite material may need repair over time if used during my treatment.
10. The restorative procedures have been explained to me, and I understand the nature of these procedures.
11. I understand that some restorative reconstruction is elective and only done for my cosmetic interest, and there are dental conditions that, if left untreated, the following may occur:
• Limited oral function.
• Gum or bone disease.
• Loss of bone.
• Inflammation infection.
• Sensitivity.
• Looseness and/or loss of teeth.
• Shifting of teeth.
• Bite changes.
• Temporomandibular joint (jaw) problems.
• An inability to have the same treatment.
• Due to the changes in oral or medical conditions, additional and more extensive treatment may have to be considered.
12. I have been advised that sugar, fizzy drinks, tobacco, prescription drugs, and alcohol may limit treatment success and require additional treatment to correct the problems. The reasons may include but are not only limited to staining, decreased tissue health, periodontal disease, gum recession, recurrent decay and fracture of teeth and restorations.
13. I agree to follow my dentist’s home care instructions and to report to my dentist for regular examinations, professional dental cleaning, and maintenance as instructed.
14. The primary cause of failure in restorative dentistry is dental caries. I will limit the consumption of sugar as far as possible and closely follow any oral health/diet advice given.
15. During or after treatment with the Doctor, I will continue to attend with my general dentist for routine dental care and hygiene visits unless indicated in writing not to do so.
16. I understand and confirm I have had the opportunity to ask and have my questions answered.
17. To my knowledge, I have given an accurate report of my physical, dental, and mental health history. If I am in any health treatment, I certify that I have discussed the proposed restorative procedures with my health care provider and received their consent to undergo it.
18. I certify that I have read, received a complete explanation, fully understand this treatment consent, and intend to undertake this treatment.
19. I have been advised about the longevity of the procedures. I have discussed the nature of the services and procedures, and I consent to the treatment knowing its risks and limitations.
20. Whilst every effort will be made to meet your cosmetic aspirations, dentistry is not an exact science, and the final cosmetic outcome can never be fully anticipated or guaranteed.
21. By signing below, I declare that I understand the proposed treatment, I am happy to proceed with it, and I consent to the commencement of treatment.