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Mon-Fr: 9:00 AM – 4:00 PM

6800 MONTGOMERY BLVD NE # C Albuquerque, NM 87109

New Patient Form

Sandia Dental Care
6800 Montgomery Blvd. N.E. Suite C
Albuquerque, New Mexico 87109
Phone (505) 884-8000

DENTAL TREATMENT CONSENT FORM


For your convenience, we make available this generalized dental consent form for you to review and sign. Please do not hesitate to ask our dental staff any questions you may have.


DRUGS AND MEDICATIONS
I understand that local anesthetics, antibiotics, and pain medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and or anaphylactic shock (severe allergic reaction).

PERIODONTAL LOSS (TISSUE & BONE)
I understand that serious gum problems can lead to bone infection or bone loss and that it can lead to the loss of my teeth. Alternative treatments include gum surgery, replacement and or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

ENDODONTIC TREATMENT (ROOT CANAL)
I realized there is no guarantee that root canal treatment will save my tooth, and that 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 (apicoectomy).

CROWNS, 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 the final opportunity to make changes in my new crown, bridge, or cap including shape, fit, size, and color will be before cementation.

REMOVAL OF TEETH
If the teeth are savable or restorable, the alternatives to removal of teeth are root canal therapy, crowns and periodontal surgery. 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 of time (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.

DENTURE, 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 include 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 visits. 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.

CHANGE IN TREATMENT PLAN
I understand that during or following treatment it may be necessary to change or add procedure because of conditions found on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedure.

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for my minor child or myself. I have had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction.