This provides the dentist with important information required for your dental treatment and oral health care.
Next of Kin / Emergency Contact:
Have you ever had any of the following? If so, please tick as appropriate
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during your treatment, our practice requires both patient and staff members to undertake a confidential blood test.
Do you agree to a blood test?
YesN.Z EuropeanMaoriSamoanCook IslandTonganChineseIndianOther
I understand that x-rays are required for the clinician to make a diagnosis.
I understand that antibiotics and analgesics and other medications’ can cause allergic reactions causing redness and swelling of tissues, pain itching, vomiting, and or anaphylactic shock severe allergic reaction
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give permission to the dentists to make any/all changes and additions as necessary after explaining to me.
Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery etc) and I authorize the dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I understand removing teeth will not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (paraesthesia) that can last for an indefinite period of time (days to months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the costs of which is my responsibility
I understand that my teeth might feel sensitive and slightly rough after my scale and prophy.
I understand that sometimes it is not possible to match the colour of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or caps (including shape, fit, size and colour) will be before cementation.
I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement and colour) will be the teeth in wax, try in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. Immediate Dentures Placement of dentures immediately after extractions may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of dentures. I understand that failure to keep my delivery appointment may result in poorly fixed dentures. If a remake is required due to my delays of more than 30 days there will be additional charges.