General Consent Form


Welcome to Smile Science Dental Spa!

At Smile Science Dental Spa, all of our dental healthcare providers constantly strive to communicate clearly and effectively with all of our patients, regarding all aspects of their dental care. There are however, many instances when sudden and unanticipated circumstances may arise, that may require the dentist or dental hygienist to provide immediate or emergency dental services.

As a patient, you have the right to accept or reject dental treatment recommended to you by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

We request that you only consent to treatment after first discussing the potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to treatment, you acknowledge that you accept known risks and complications.

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre- and post-treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. Failure to follow the advice of your dentist may increase the chances of a poor outcome.

As a patient, you are an important part of the dental treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so that they can be addressed by your dentist.

Consent to Dental Treatment

I authorize dental treatment including necessary or advisable examination, radiographs (x-rays), diagnostic aids or local anesthesia.

In general terms, dental treatment may include but is not limited to one or a number of the following:

  1. Administration of local anesthesia
  2. Cleaning or the teeth and application of topical fluoride
  3. Scaling and root planing (deep cleaning) with local anesthesia
  4. Application of sealants to the grooves of the teeth
  5. Treatment of diseased or injured teeth with dental restorations
  6. The replacement of missing teeth with a dental prosthesis (crown, partials, implants, etc.)
  7. Treatment of diseased or injured oral tissues (hard and/or soft)
  8. Treatment of malposed (crooked) teeth and/or developmental abnormalities.
  9. Treatment of the canal or pulp chamber that lies in the middle of the tooth and its root also known as “endodontic” therapy or root canal

Risk of Dental Procedures in General

Included (but not limited to) are complications resulting from the use of dental instruments, drugs, medicines, analgesics (pain killers), anesthetics and injections. Some of the more commonly known risks and complications of treatment include, but are not limited to the following:

  1. Pain, swelling, bleeding, and discomfort after treatment
  2. Infection in need of medication, follow-up procedures or other treatment.
  3. 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
  4. Reaction to injections or medications
  5. Itching, bruising, delayed healing
  6. Damage to adjacent teeth, restorations or gums
  7. Possible deterioration of your oral health condition which may result in tooth loss
  8. The need for replacement of restorations, implants or other appliances in the future
  9. An altered bite in need of adjustment
  10. Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist
  11. Temporomandibular jaw (TMJ) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues.
  12. 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
  13. Need for follow-up treatment, including surgery
  14. Medication and drugs may cause drowsiness and lack of awareness and coordination (which can be influenced by the use of alcohol or other drugs), thus it is advisable not to operate any vehicle or hazardous device, or work for twenty-four hours or until recovered from their effects.

Cardiac Conditions

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

Birth Control

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

Changes in Treatment Plan

I understand that during treatment, it may be necessary to change and/or add procedures because of conditions found while working on the teeth that were not discovered during initial examination. Upon my consent, I will give permission to the dentist to make any/all changes and additions as discussed and deemed necessary.


I understand that I may experience hot and cold sensitivity, pain or discomfort following routine restorative procedures and that this is usually temporary and should settle without further treatment. If in the event that my condition does not get any better, I understand that I may need further dental treatment, the most common being root canal therapy, resulting in additional costs.

Crowns (Caps), Bridges and Onlays

I understand that sometimes it is not possible to match the color of artificial teeth with natural 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 realized the final opportunity to make changes in my new crown or bridge (including shape, fit, size and color) will be before cementation. Once cemented, I understand that any changes in shape, fit, size or color will incur an additional charge.

Alternative Treatment

I understand that I have the right to choose, on the basis of adequate information, from alternate treatment plans that meet professional standards of care.

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 of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.

Dental Insurance Information

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