CONSENT TO PERFORM DENTISTRY
I hereby authorize and direct Dr. Kevin Mosmen and/or dental auxiliaries of his choice, to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays) or diagnostic aids.
Preventive hygiene treatment (prophylaxis) and the application of topical fluoride.
Application of resin “sealants” to the grooves of the teeth.
Treatment of diseased or injured teeth with dental restorations (fillings and crowns).
Replacement of missing teeth with dental prostheses (fixed bridges, removable partial or full dentures, implants).
Removal (extraction) of one or more teeth
Treatment of diseased or injured oral tissues (hard and soft).
Use of sedative drugs to control apprehension and/or disruptive behavior.
Treatment of malposed (crooked) teeth and/or oral development or growth abnormalities.
I understand that there are risks involved in this treatment and hereby acknowledge that this risk(s) will be explained to me, that I will have an opportunity to ask questions regarding the treatment and risks, and that I fully understand the same.
I agree to the use of local anesthetics and the use of nitrous oxide analgesia depending on the judgment of the office. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nose piece leaves an indentation or ring around the nose which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.
I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed eing in the professional judgment of Dr. Mosmen.
There are possible risks and complications associated with dentistry and the administration of local anesthesia, sedation, and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, numbness of the lips, gums, face, and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, and lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that either are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma and death. I understand and have been informed of the above risks and complications.
I authorize Dr. Mosmen to use photographs, radiographs, other diagnostic materials and treatment records for the purpose of teaching, research, marketing of the practice, and scientific publications.
I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of Dr. Mosmen and his employees. I agree that the success of the treatment requires that all post-operative and post-care instructions are to be followed and that regular office visits as scheduled by the office must be maintained.
I understand that I need to provide the office AT LEAST 36 hours notice to cancel or reschedule an appointment. If I cannot, and I reschedule with less than 36 hours notice or fail to show for my appointment, I understand that I may be charged $55 for each occurrence. I acknowledge that this fee may be incurred to merely cover the operating expenses of the office.
I hereby state that I have read and understand this consent and that all questions about the procedures will be answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment.
I further understand that this consent will remain in effect until such time that I choose to terminate it.