You have the right to accept or reject dental treatment recommended by your dentist. Do not consent to treatment until you discuss potential benefits, risks, and complications with your dentist. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to, the following:

Pain, swelling, and discomfort after treatment
Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist
Temporary, or, on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste
Damage to adjacent teeth, restorations, or gums
An altered bite in need of adjustment
Possible deterioration of your condition which may result in tooth loss
Jaw fracture
Allergic reaction to anesthetic or medication
A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed at a later point in time
If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment
Infection in need of medication, follow-up procedures, or other treatment
The need for replacement of restorations, implants, or other appliances in the future
Need for follow-up care and treatment, including surgery
Prolonged numbness

The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments;

it is important to report any problems or complications you experience so they can be addressed by your dentist.

If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise your dentist immediately so he/she can consult with your physician if necessary.

If you are a woman on birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes antibiotics or if you are taking antibiotics.

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks and complications or recommended treatment with your dentist. Be certain all your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

Authorizations

This section provides consent for treatment as well as permission for the payer to send any patient benefit available for procedures performed directly to the dental practice.

Patient Consent: The patient is defined as an individual who has established a professional relationship with the dentist for the delivery of dental health care. For matters relating to communication of information and consent, the term includes the patient's parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case. By signing (or "Signature on File" notice) in this location of the claim form, the patient or patient's representative has agreed that he/she has been informed of the treatment plan, the costs of treatment and the release of any information necessary to carry out payment activities related to the claim.

Claim forms prepared by the dentist's practice management software may insert "Signature on File" when applicable in this Item.

Authorize Direct Payment: The signature and date (or "Signature on File" notice) are required when the Policyholder/Subscriber wishes to have benefits paid directly to the

dentist/provider. This is an authorization of payment. It does not create a contractual relationship between the dentist or dental entity and the insurance company.

Claim forms prepared by the dentist's practice management software may insert "Signature on File" when applicable in this Item.

Assignment of Benefits Form

I hereby assign all dental benefits and authorize and direct my insurance carrier(s) to issue payment check(s) directly to Reardon Dental for dental services rendered to myself and/or my dependents regardless of my insurance benefits if any. I understand that I am responsible for any amount not covered by insurance.

Authorization of Release Information

I hereby authorize Reardon Dental to: (1) release any information necessary to insurance carriers regarding my treatment; (2) process insurance claims generated during examination or treatment; (3) allow my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.

I have requested dental services from Reardon Dental on behalf of myself and/or my dependents and understand that by making this request, I become fully responsible for all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred that my insurance does not cover, upon presentation of the appropriates statement. A photocopy of this assignment is to be considered as valid as the original.