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Patient Consent Form
Informed Consent for Dental Treatment


Proposed treatment taking of intraoral and extraoral radiographs. Benefits of treatment: taking x-rays
enables us to view dental cavities, abnormalities, development and eruption of
teeth. They are also necessary for proper diagnosis and evaluation purposes. Alternatives of treatment: none;
limited visual examination. Common
risks: radiation exposure to soft and hard tissues. Consequences of not performing the
treatment: missed diagnosis.

Root Canal Treatment and Pulpotomy:

Proposed treatment: to remove infected pulp tissue and replace with root canal filling
Benefits of treatment: eliminate
pain, infection, swelling and further destruction of tooth structure. Alternatives of treatment: extraction. Common risks: recurrence of
symptoms, breakdown of tooth structure. Consequences
of not performing the treatment: increase in severity of pain, swelling,
infection, and possible hospitalization and rare instances death.


Proposed treatment: involves thorough cleaning of teeth to help heal inflamed or
infected gum tissue. It involves removal of solid plaque build-up and  harder calculus deposits above and below the
gum line. Benefits of treatment: healthy
oral environment; also,  reduction/elimination of bleeding, odor and periodontal disease. Alternatives of treatment: referrals for periodontal (gum) surgery according to the severity of condition. Common risks: bleeding, soreness,
swelling, Infection of tissue, hot and cold sensitivity, stiff or sore jaw joint. Consequences of not performing
the treatment: discontinued or interrupted treatment could result into
further inflammation and infection of gum tissues; lead to more tooth decay,
and deterioration of surrounding bone structure which could lead to tooth loss.

Crown and Bridge:

Proposed treatment: to strengthen a tooth damaged by decay or previous restoration,
and protect a tooth that has had root canal treatment. Improve the biting
surface, appearance of damaged, discolored, poorly spaced and/or missing teeth.
Benefits of treatment: to restore
or improve the appearance and strength of teeth. Alternatives of treatment: extraction or Orthodontic treatment
(only in proper spacing, not damaged teeth). Common risks: irritation to surrounding tissue, inflammation,
irritation to nerve tissue, stiff or sore jaw joint. Sensitivity to hot and
cold, also possible root canal treatment. Consequences of not performing the treatment: further
destruction, nerve exposure, loss of tooth function, root canal treatment.


Proposed treatment: injection of anesthetic to surrounding oral tissues. Benefits of treatment: numbness of
tissue and muscle surrounding area of treatment to eliminate pain sensation. Alternatives to treatment: dental
restorations performed with no anesthetic resulting in severe sensitivity and
pain. Common risks: allergic
reaction, irritation to nerve tissue, stiff or sore jaw joint, swelling of
tissue, bruising and may cause temporary or permanent paralysis. Consequences of not performing the treatment: severe pain
and sensitivity.


Proposed treatment: removal of unreasonable tooth structure and roots. Benefits of treatment: elimination of
pain, infection, swelling. Alternatives
of treatment: none. Common
risks: infection, bleeding, soreness, bruising, damage to adjacent teeth
and soft tissue, dry socket, opening into sinuses, tooth and bone fragments,
bone fracture, chronic hot and cold sensitivity, temporary and or permanent
numbness, and destruction of bone and soft tissue. Consequences of not performing
the treatment: severe pain, swelling, infection, possible
hospitalization with rare cases of death.


Proposed treatment: to remove dental caries and replace with filling material to
regain proper tooth anatomy. Benefits
of treatment: restore tooth structure for proper function. Alternatives of treatment: temporary
filling, crown, extraction. Common
risks: allergy to filling material, tooth sensitivity, filling may come
out. Consequences of not performing
the treatment: further spread of decay, requiring root canal treatment
or severe destruction resulting in tooth loss.

Thanks for submitting!

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