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