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Sacramento Natural Dentistry

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Informed Consent For Dental Procedure

Dr. Azouz has thoroughly discussed and I understand the above procedure. I have been told of the treatment alternatives including having no treatment at all. I have further been advised of the risks and possible consequences of the above procedure. I have freely elected to proceed with the procedure and I am willing to take such risks. Further, I will hold Dr. Azouz harmless for complications, risks, or consequences arising from this procedure.

* DRUGS AND MEDICATIONS - I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and welling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
* CHANGES IN TREATMENT PLAN - I understand that during treatment it may be necessary to change or add procedure 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 Dr. Azouz to make any/all changes and additions as necessary.
* FILLINGS - Dental fillings may require additional treatment and/or sensitivity with new dental restorations.
* SCALING/ROOT PLANNING - Deep cleaning may result in sensitive teeth and/or sore gums. Reduction in swelling of the gums may expose more tooth surface.
* COSMETIC PROCEDURES - may result in exposed nerves, needing root canal, post and crown.
* ENDODONTIC TREATMENT - I realize there is no guarantee that root canal treatment will save my tooth and those complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment.
* CROWN, BRIDGES, AND CAPS - I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial 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 realize that the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size, and color) will be before cementation.

(Your digital signature (full name) is as legally binding as a physical signature.)