Consent Form

On this date I have approved of the aesthetics of the dental treatment Dr. Kullberg is currently rendering me.

Dental Treatment Consent Form

Please read sign and initial next to every checked box

1. DRUGS AND MEDICATIONS

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock(severe allergic reaction)

2. CHANGES IN TREATMENT PLAN

I understand that altering procedures may be necessary due to conditions found during treatment not originally diagnosed at examination; the most common being root canal therapy following routine restorative procedures. I permit the Dentist to make any/all changes and additions as necessary.

3. REMOVAL OF TEETH

Alternatives to removal have been explained to me (root canal therapy, crowns and periodontal surgery) and I authorize the Dentist to remove the following teeth,

. 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, inducting but not limited to; pain, swelling, spread of infection, dry socket, loss of feeling in teeth, lips, tongue and surrounding tissue (Paresthesia) for an indefinite period of time (days or months) of 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.

4. CROWNS, ONLAY, INLAY, 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.

5. ALL PORCELAIN RESTORATIONS

I understand that all porcelain restorations by the nature of the material and its properties pose a risk for breakage and chipping. I understand that it becomes my full responsibility (financially) to accept any risk involved.

6. DENTURES, COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. Toe 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.

7. ENDODONTIC TREATMENT (ROOT CANAL)

I realize there is no guarantee that root canal treatment will save my tooth, and complications may occur from the treatment. Occasionally metal objects are cemented in the tooth or extended 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).

8. PERIODONTAL LOSS (TISSUE & BONE)

I understand that I have a serious condition, causing gum and bone inflammation that may lead to the loss of teeth. Alternative treatment plans have been explained to me, (gum surgery, extractions etc.) I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

9. FILLINGS

I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I Understand that significant sensitivity is a common after effect of a newly placed filling.

I understand that dentistry is not an exact science, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

Non-Covered Service Disclaimer

Zirconia or EMAX Crowns Financial Agreement

Dear Valued Patient;

Your doctor and dental team have reviewed your treatment plan and recommend the placement of a crown(s) as your best course of action.

You are enrolled with an insurance plan with which we are currently contracted and have agreed to reduce our fees for covered services by your insurance carrier.

We arc excited to let you know that our office will only perform procedures that are use the best techniques and qualities. Unlike insurance covered crowns, Zirconia crowns include material that may last a lifetime. Also, if you are receiving an EMAX crown, EMAX material includes a number of aesthetic/cosmetic properties that are simply not included under your insurance policy. As you can sec below, the benefits of Zirconia or EMAX crowns are immense and provide you with much greater quality of care, in addition to saving you valuable time.

Traditional Insurance Crowns

  • High Risk of cracking or fracturing
  • High Risk of chipping or breaking
  • Inexpensive and less reliable materials
  • No aesthetics or cosmetics included
  • Old and relatively unreliable technology
VS

Zirconia and EMAX Crowns

  • 100% high-quality porcelain; no metal
  • Zirconia material may last a lifetime
  • Zirconia may include aesthetic properties
  • EMAX include beautiful aesthetic properties Zirconia and EMAX are High Quality
  • Crowns include a 5 year warranty

At Integrity Dental we are committed to the highest quality of dental care and use only the strongest, most durable materials available as pa1t of our pledge to help you retain your teeth for a lifetime. These quality materials are more costly than those prescribed by your insurance plan so, in addition to your patient portion of responsibility, a one-time material and warranty fee for Zirconia and EMAX Crowns $75.00 will be due at the time treatment commences. These are strictly material fees that you choose to receive in addition to the prescribed crown treatment. Your coinsurance/copay is separate from this material fee election. Warranty will be void if your crown fails due to neglect of personal oral care. The material fees are considered a non-covered service and as such will not be billed to insurance but billed to you directly. You have a legal right to obtain service that are above and beyond the scope of insurance if you choose to invest in higher quality services on your own and outside of the limitations of insurance coverage.

As always, we arc committed to serving you in the most efficient and effective way possible and to meeting all your dental care needs in our comprehensive dental facility. We truly value our patients and want to thank you for your continued confidence in our practice.

I understand and agree to pay the above referenced fees associated with my Zirconia or EMAX crown(s).

Health History Update

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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