Self Assessment
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crown and bridge prosthetics
File Number:
Informed Consent for Crown and Bridge Prosthetics
Recommended Treatment
I hereby give consent to Dr.
to perform Crown and Bridge Prosthetics procedure(s) on me or my dependent as follows:
and any such additional procedure(s) as may be considered necessary for my well- being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.
Treatment Alternatives
Alternative methods of treatment have been explained to me, such as:
but I wish to proceed with the Recommended Treatment described above.
Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:
1. Reduction of tooth structure.
2. Sensitivity of teeth.
3. Crown or bridge abutment teeth may require root canal treatment.
4. Breakage.
5. Uncomfortable or strange feelings, which is typically temporary. In limited situations, muscle soreness or tenderness of the jaw may persist following placement of the prosthesis.
6. Unsatisfactory aesthetics or appearance.
7. Unsatisfactory longevity of crowns and bridge.
8. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
Patient Name
Patient Signature
Date / Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
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