Crowns and Bridges Consent Form

Crowns and Bridge Release Form
I understand that the treatment of dental conditions requiring crowns or fixed bridgework may involve certain risks and possible unsuccessful results, including procedural failure. I understand that care and diligence are exercised in each treatment, and that treatment will only proceed if there is a reasonable chance of success. I understand that there are potential risks in any treatment plan or procedure and that in this specific instance such risks may include, but are not limited to the following:
Reduction of tooth structure : in order to replace decayed or otherwise traumatized teeth it is necessary o modify the existing tooth before crowns/bridges are placed on them;
Sensitive Teeth : sometimes after teeth have been drilled on, they may exhibit mild to severe sensitivity. Usually, this only lasts for a short period of time but may also last for a much longer period. If sensitivity is persistent please notify the office immediately so the cause of sensitivity can be determined;
Crowned or bridge teeth may require root canal treatment subsequently: after being crowned, a tooth may develop pulpitis or pulpal degeneration. This usually cannot be determined prior and may be a result of trauma from pre-existing deep decay or preparation of the tooth. It is often necessary to do root canal treatment on these teeth particularly if they remain sensitive for a prolonged period. Infrequently, the tooth may become abscessed or not heal completely and may need periapical surgery or extraction. These services would be an additional cost to the patient;
Breakage: crowns/bridges occasionally chip or break. This can result because of chewing excessively hard materials, traumatic injuries, tooth clenching or grinding, etc. Unobservable cracks may happen from these causes, but the crown/bridge may not actually break until a later date when chewing soft foods or for no apparent reason. Breakage rarely occurs due to defective materials or construction unless it occurs soon after placement; and
Esthetics or appearance: patients will be given the opportunity to check the appearance of crowns/bridges before final cementation. Once cemented the appearance cannot be changed.
Consent*
I understand that it is the patient’s responsibility to contact the dental office should any unexpected problems occur. I agree to follow instructions, including scheduling and attending all follow-up appointments. I understand that a failure to keep a cementation appointment can result in failure of the crown/bridge to fit properly.
Consent*
I understand the nature, purpose, and possible risks of treatment and have been given the opportunity to ask any questions. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness.*
Consent*
I understand the above and agree to the procedure.*
Treatment Provided by:
Tooth*
Please ask the office staff for more details
Today's Date*
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Name*
First Name Last Name
Signature*

Spruce Grove Alberta and Stony Plain Dental Clinic
Company	North Stony Dental
Services	Dentistry, Orthodontics, Invisalign, Emergency Dental, Myobrace
Founded	2017
Area Served	Spruce Grove and Stony Plain
Pricing	$$

Days	Hours of Operation
Monday	8:00 AM–4:00 PM
Tuesday	8:00 AM–4:00 PM
Wednesday	9:00 AM–6:00 PM
Thursday	9:00 AM–6:00 PM
Friday	8:00 AM–3:30 PM
Saturday	Closed
Sunday	Closed

Crowns and Bridges Consent Form

Crowns and Bridge Release Form

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