Patient Form

First Name

Surname

ID Number

Title

Home Address

Home telephone & code

Cell phone number

Occupation/position

Employer

Work Address

Work telephone and code

Emergency contact

E-mail Address

Name of option

Medical aid number

Dependant Number

First Name

Surname

ID Number

Title

Home Address

Home telephone & code

Cell phone number

Occupation/position

Employer

Work Address

Work telephone and code

Emergency contact

Patient’s Name:

* Patient's Email Address:

1. X-RAYS (may be taken) Initials

2. DRUGS AND MEDICATIONS
I understand that antibiotics and pain medications and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).Please be honest about your medical history. Initials

3. CHANGES IN TREATMENT PLAN
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 my permission to the Dentist to make any/all changes and additions as necessary. Initials

4. REMOVAL OF TEETH
Alternatives to removal have been explained to me (root canal therapy, crowns, and 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 does 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 (Paresthesia) that can last for an indefinite period (days or 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 cost of which is my responsibility. Initials

5. DENTURES, COMPLETE OR PARTIAL
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 color) 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. I understand the wearing of dentures is difficult. Sore spot, altered speech and difficulty in eating are common problems. 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 the 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. Initials

6. ENDODONTIC TREATMENT (ROOT CANAL)
I realize there is no guarantee that root canal treatment will save my tooth, and that complications, such as, fracture of root canal files, increase of infection, perforation of tooth, post operative pain, sodium hypochlorite incident etc. can occur from the treatment. Initials

7. PERIODONTAL LOSS (TISSUE & BONE) (Scale and polish)
These teeth may be lost due to loss of bone. A scale and polish may be carried out as prophylaxis (post treatment sensitivity and pain and possible increased mobility can occur following a cleaning. Initials

8. FILLINGS I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that significant sensitivity is a common after effect of a newly placed filing. And that if cavities are deep and close to the nerve, there is a possibility of pain which will require further treatment to alleviate the pain. This will cost more and should this occur, the cost will fall upon me. Initials

9. CROWNS AND BRIDGES
I understand that preparing teeth for crowns or bridges requires the permanent removal of tooth structure. Possible complications include sensitivity, pain, gum irritation, decay, fracture, loosening or failure of the restoration, changes in appearance or bite, and the possible need for root canal treatment, replacement, extraction, or other treatment. I understand that temporary crowns or bridges may loosen or break and that I must contact the dental practice if this occurs. I understand that the colour and appearance of the final restoration may not be an exact match to natural teeth. The expected lifespan of a crown or bridge cannot be guaranteed and depends on factors including oral hygiene, diet, tooth grinding, and attendance at follow-up visits. Initials

10. ORTHODONTIC TREATMENT (BRACES AND CLEAR ALIGNERS)
I understand that orthodontic treatment with braces or clear aligners may cause discomfort, tenderness, mouth irritation, temporary difficulty speaking or eating, and changes in the bite. Possible complications include tooth decay, permanent white marks or discolouration, gum inflammation, gum recession, loss of supporting bone, shortening of tooth roots, tooth sensitivity, loss of tooth vitality, jaw-joint symptoms, and damage to existing fillings, crowns, bridges, implants, or other dental work. Teeth that have previously been injured or heavily restored may require additional treatment, including root canal treatment. I understand that successful treatment depends on maintaining good oral hygiene, attending appointments, following instructions, wearing aligners or elastics as directed, and avoiding foods or habits that may damage the appliances. Treatment may take longer than estimated, and additional procedures such as attachments, enamel reduction, extractions, restorations, or referral to another practitioner may be recommended. Lost, damaged, or replacement appliances may result in additional charges. I understand that teeth may move again after treatment. Retainers must be worn as instructed, and replacement or further treatment may be required at an additional cost. I understand that orthodontic treatment cannot guarantee a perfectly stable, functional, or aesthetic result. The proposed treatment, alternatives, limitations, risks, expected duration, and fees have been explained to me, and I have had an opportunity to ask questions. Initials

Signature of Patient or Signature of Parent/Guardian if patient is a minor

Clear

Date: