Louisiana Center for Restorative Dentistry

Pre Op

Consent for Dental Treatment and Acknowledgement of Information

State law requires us to obtain your consent for dental treatment. Please ask us about anything you do not understand and we are ready to answer any of your questions or explain anything concerning your treatment.

Any alternatives to the recommended treatment, including no treatment, have been explained to me. In general terms the contemplated dental treatment is: ________________________________________________________

There are risks associated with any dental treatment. This includes the administration of any local or general anesthetic agent, analgesic agent to produce conscious sedation, and/or premedication prior to dental care being rendered. Some of these risk/ complications are, but not limited to the following:

• Infection
• Bleeding
• Failure of wounds to heal
• Injuries to adjacent teeth and/or soft tissue
• Paresthesia or numbness of: tongue, mouth, face
• Fracture of mandible (lower jaw) or maxilla (upper jaw)
• Opening between the mouth and sinus
• Incomplete removal of teeth
• Dry socket
• Loss of teeth or bone
• Slough (unanticipated loss of hard or soft tissue)
• Injury adjacent structures
• Instrument breakage
• Breakage of roots and retained fragments
• Swallowing or aspiration of objects
• Allergic reaction to drugs
• Trismus (jaw pain or difficulty opening mouth)
• Failure of treatment to accomplish its purpose
• Death (in rare instances)
• Bacterial endocarditis
• Additional oral surgery, hospitalization, and/or further treatment may be required in the event of any complications.
• State law also requires that I specifically advise you that although rarely occurring, dental treatment or anesthetic may result in : death, brain damage, quadriplegia, loss of organ, loss of function of an organ, loss of function of face, arm, leg, and disfiguring scars.

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