Consent Forms

Your Details

Name(Required)

Email(Required)

Enter Email Confirm Email

To receive a copy of this form please enter your email

DOB

Hidden

Location

Treated By

Consent Form Type

Consent for a Composite Veneer

As with all medical procedures, there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Common risks and complications

Composite has an average lifespan of 6 years.
It can chip, fracture and stain over time.
The composite is translucent, therefore any underlying discolorations may sometimes be visible.
Due to normal wear and tear, your composite veneers will require maintenance in the future. They can be repaired or replaced at an additional cost.
Newly placed composite will look different to any existing restorations you may have in adjacent teeth, such as old composite restorations and porcelain restorations.

Rare risks and complications

If the tooth has decay or an existing restoration which needs to be removed, there is a chance the nerve inside the tooth may become inflamed and painful, in which case the tooth may require root canal treatment or extraction.
Allergic reaction to something used during the procedure.

Alternative options

Treating the tooth in a different way such as porcelain veneers or orthodontic treatment as discussed in your consultation.
Having no treatment carried out.

Patient Signature(Required)

Date of Signature(Required)

Consent for a Composite Veneer Removal

Composite veneer removal is the reversal of placement of the composite veneers. It is a time consuming job and will roughly take the same length of time as placement. The process involves drilling the composite away from the teeth slowly, leaving behind the natural underlying teeth.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Risks

The main risk associated with removal of composite, is that the process can damage the underlying tooth.
The composite must be drilled away from the tooth slowly. As the composite is strongly bonded to the enamel, it is highly likely some enamel will be removed in the process of drilling the composite.
Once the composite has been removed, the teeth may not appear the same as they did prior to placement - relating to shape and shade. The teeth may become sensitive after the composite is removed.

Alternative options

Do nothing – leave your existing composites and allow them to settle and adapt
Adjustment of your existing composite – reshape/repolish
Replacement with alternative material such as porcelain – these can provide a more tooth like appearance, however the shape will need to be similar to fill the spacing.

Patient Signature(Required)

Date of Signature(Required)

Consent for a Composite Veneer

Composite veneers are the placement of a white composite filling material over the front surface or edges of teeth. This can be used to change tooth shape and increase size. It can also provide protection/reinforcement if the tooth has been weakened. Composite veneers often involve no drilling of the natural tooth.
As with all medical procedures, there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Common risks and complications

Composite has an average lifespan of 6 years.
It can chip, fracture and stain over time.
Composite is translucent; therefore any underlying discolorations may sometimes be visible.
Due to normal wear and tear, your composite veneers will require maintenance in the future. They can be repaired or replaced at an additional cost.
Newly placed composite will look different to any existing restorations you may have in adjacent teeth, such as old composite restorations and porcelain restorations.
Composite is not easy to remove. It will require drilling to remove which has a risk of removal of some underlying tooth structure.
Composite cannot be whitened. If you plan to whiten the teeth this needs to be completed prior to placing the composite. We would strongly advise using our whitening kit, as we cannot guarantee the longevity of third-party kits. Please do not whiten teeth within 2 weeks of the procedure.

Rare risks and complications

If the tooth has decay or an existing restoration which needs to be removed, there is a chance the nerve inside the tooth may become inflamed and painful, in which case the tooth may require root canal treatment or extraction.
Allergic reaction to something used during the procedure.

Alternative options

Treating the tooth in a different way such as porcelain veneers or orthodontic treatment.
Having the veneers modelled prior to the procedure using direct composite as a mock-up (chairside) or taking impressions and modelling the veneers with wax on stone models (lab made)
Having no treatment carried out.

Before and after the procedure we will also take photographs of your teeth. These photographs will be used for your clinical records but can also sometimes be used for educational and marketing purposes. If the photographs are used, they will be anonymised so that you are not identified.

Patient Signature(Required)

Date of Signature(Required)

Consent for a Crown or Onlay

Placing a crown is a dental procedure during which the tooth is shaped and a lab made custom restoration is made and fitted to the tooth. The intended benefits of the procedure include returning the tooth to its correct shape and good strength.

Expected complications

Numbness lasting a few hours.
Soreness of the gums lasting a few days.

Common risks and complications

Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
Some teeth will be sensitive for some time after the procedure.
Darkening of the root of the tooth depending on the material used.
Inability to return the tooth to a perfect shape which could result in it being more difficult to look after.

Rare risks and complications

Removing tooth material to make space for the crown can irritate the nerve inside the tooth sometimes leading to the nerve dying and causing toothache.
Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
Allergic reaction to something used during the procedure.

Crowns are not successful 100% of the time even if all parts of the procedure go as planned. The tooth may not have enough strength left prior to this procedure for a long term result. Decay and previous work may have irritated the nerve which could result in toothache in the future. Therefore, some teeth that have undergone this procedure will require a root canal treatment or might require extraction.

Alternative options

Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment.
Treating the tooth in a different way such as extraction
Refusing treatment but this will result in high risk of further pain and infection from this tooth.

Patient Signature(Required)

Date of Signature(Required)

Consent for a Filling

Placing a filling is a dental procedure during which decay is removed from a tooth and the cavity is restored with a filling material. The intended benefits of the procedure include the removal or prevention of pain and returning the tooth to its correct shape.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Expected complications

Numbness lasting a few hours.
Soreness of the gums lasting a few days.

Common risks and complications

Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
Some teeth will still be sensitive for sometime after the procedure.
Darkening of the tooth depending on the material used.
Inability to return the tooth to a perfect shape which could result in it being more difficult to look after.

Rare risks and complications

Weakening of the tooth being treated meaning it might require further work in the future to restore it to decent strength.
Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
Allergic reaction to something used during the procedure.

Fillings are not successful 100% of the time even if all parts of the procedure go as planned. The decay may have irritated the nerve which could result the tooth being painful in the future. Therefore, some that have undergone this procedure will require a root canal treatment or might require extraction.

Alternative options

Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment.
Treating the tooth in a different way such as extraction or crowning the tooth.
Refusing treatment but this will result in high risk of further pain and infection from this tooth.

Patient Signature(Required)

Date of Signature(Required)

Consent for Composite Bonding

Common risks and complications

Composite has an average lifespan of 6 years.
It can chip, fracture and stain over time.
Composite is translucent; therefore any underlying discolorations may sometimes be visible.
Due to normal wear and tear, your composite veneers will require maintenance in the future. They can be repaired or replaced at an additional cost.
Newly placed composite will look different to any existing restorations you may have in adjacent teeth, such as old composite restorations and porcelain restorations.
Composite is not easy to remove. It will require drilling to remove which has a risk of removal of some underlying tooth structure.
Composite cannot be whitened. If you plan to whiten the teeth this needs to be completed prior to placing the composite. We would strongly advise using our whitening kit, as we cannot guarantee the longevity of third-party kits. Please do not whiten teeth within 2 weeks of the procedure.

Rare risks and complications

If the tooth has decay or an existing restoration which needs to be removed, there is a chance the nerve inside the tooth may become inflamed and painful, in which case the tooth may require root canal treatment or extraction.
Allergic reaction to something used during the procedure.

Alternative options

Treating the tooth in a different way such as porcelain veneers or orthodontic treatment.
Having the veneers modelled prior to the procedure using direct composite as a mock-up (chairside) or taking impressions and modelling the veneers with wax on stone models (lab made)
Having no treatment carried out.

Patient Signature(Required)

Date of Signature(Required)

Consent for a Denture

Constructing a denture is a dental procedure in which a removable prosthesis is custom made for the mouth to replace one or more missing teeth. The intended benefits of the procedure include cosmetic and functional improvements for the mouth.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Expected complications

Dentures are by definition a removable prosthesis and therefore do not work like natural teeth.
They must be removed for cleaning and kept out of the mouth at night.
Most people find that dentures can sometimes move or be dislodged while wearing.
Requirements for adjustments, relining or remaking the denture in the future.

Common risks and complications

Dentures may rub on the gums and cause ulcers.
Some dentures put additional stress on remaining teeth, fillings or crowns resulting in additional work being required in the future.
Dentures that are broken or lost will result in having to be sent away for repairs. This will mean that you may be without your denture until it has been repaired at the laboratory.

Rare complications

Allergic reaction to something used in the procedure.
Dentures are not successful 100% of the time even when all parts of the procedure go as planned.
Some people struggle with dentures even if they are technically excellent and may wish to replace the missing teeth in a different way.

Alternative options

Refer to a specialist in this field who may be able to treat the case better via use of specialist equipment.
Replacing the teeth in a different way such a bridge or an implant (if medically and clinically possible).
Refusing treatment but this will result in the situation remaining as it is.

Patient Signature(Required)

Date of Signature(Required)

Consent for Wisdom Tooth Extraction

A wisdom tooth extraction is removal of one of your third molars. This can be either a simple extraction, or if the tooth is impacted it may require surgical removal. Surgical removal involves making an incision in the gum to expose the bone surrounding the tooth, removal of some of this bone and removal of the whole tooth and roots. Some sutures (stitches) may also be required at the end.

Expected complications

Numbness lasting a few hours.
Soreness, bleeding, bruising and localised swelling lasting up to a week.

Common risks and complications

Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
Prolonged post-operative pain due to poor healing or infection.
Fracture of the tooth during the procedure which can lead to further treatment being required to remove the piece of tooth/root being

Rare risks and complications

Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
Allergic reaction to something used during the procedure.

Patient Signature(Required)

Date of Signature(Required)

Consent for Extraction

An extraction is a dental procedure which a tooth is removed because it has a major problem and has not got a good long term prognosis. The intended benefits of the procedure include removal of pain and/or infection or aiming to make the mouth less prone to future problems.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Expected complications

Numbness lasting a few hours.
Soreness, bleeding, bruising and localised swelling lasting up to a week.

Common risks and complications

Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
Prolonged post-operative pain due to poor healing or infection.
Fracture of the tooth during the procedure which can lead to a surgical procedure being required or a piece of tooth/root being left because it cannot be removed.

Rare risks and complications

Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
A communication (hole) between the mouth and the sinus when removing upper teeth.
Displacement of part of the tooth in the sinus.
Allergic reaction to something used during the procedure.

Alternative options

Referral to a specialist in this field who may be able to treat the tooth better via the use of specialist equipment.
It may be possible to save the tooth with different treatment such as a root canal treatment etc.
Refusing treatment but this will result in high risk of further pain and infection from this tooth.

Patient Signature(Required)

Date of Signature(Required)

Consent for Periodontal Treatment

Periodontal treatment is a dental procedure during which the teeth are cleaned above and below the gums. The intended benefits of the procedure include the elimination of active periodontal disease (also called gum disease) aiming to prevent the loss of teeth.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Expected complications

Numbness lasting a few hours
Soreness of the gums lasting a few days
Requirement for maintenance cleaning in the future.

Common risks and complications

Trauma to other parts of the mouth including teeth, gums, cheeks, tongue etc.
Some teeth will have increased sensitivity for some time after the procedure.
Inability to clean the tooth well enough to control the periodontal disease, meticulous oral hygiene at home is paramount.
Cosmetic changes to the gums.

Rare risks and complications

Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
Allergic reaction to something used in the procedure.

Periodontal treatment is not successful 100% of the time even if all parts of the procedure go as planned. Therefore, some teeth that have undergone this procedure will require further treatment or might require extraction.

Alternative options

Referral to a specialist in this field who may be able to treat the tooth better via the use of specialist equipment.
Treating the tooth in a different way such as an extraction
Refusing treatment but this will result in high risk of further loss of gum strength ultimately leading to loss of some teeth.

Patient Signature(Required)

Date of Signature(Required)

Consent for Root Canal Treatment

Root canal treatment (RCT) is a dental procedure during which the nerve is removed from a tooth normally because the nerve is dying or has died. The intended benefits of the procedure include removal of pain and/or infection at the base of the tooth. This procedure will not prevent future tooth decay, tooth fracture, or gum disease, and occasionally a tooth that has had root canal treatment may require re treatment, endodontic surgery, or tooth extraction.
As with all medical procedures, there are risks and potential complications, which you must be aware of before you, can give your consent to proceed.

Expected complications

Numbness lasting a few hours
Soreness of the gums lasting a few days

Common risks and complications

Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue etc.
Weakening of the tooth being treated meaning it might require further work in the future to restore it to decent strength.
Darkening of the tooth.
Inability to locate, clean and seal all parts of the root canal resulting in failure to remove all pain and/or infection.

Rare risks and complications

Fracture of the tooth resulting in extraction of the tooth being required.
Separation (fracture) of an instrument within the tooth.
Perforation of the floor or the root of the tooth by any instrument.
Trauma to the tissues underneath the tooth including bone, sinus, nerves supplying other teeth etc.
Tissue damage or allergic reaction to something used during the procedure.

Root canal treatment is not successful 100% of the time even if all parts of the procedure go as planned. Therefore, some teeth that have undergone this procedure will require the RCT to be redone or might require extraction.

Alternative options

Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment.
Extraction leading to a gap or further work to replace the tooth such as a denture, a bridge or an implant.
Refusing treatment but this will result in high risk of further pain and infection from this tooth.

Patient Signature(Required)

Date of Signature(Required)

Consent for Tooth Whitening

Tooth whitening is a dental procedure during which a peroxide solution is used to permanently change the colour of the teeth. The intended benefits of the procedure include returning the teeth back to the shade they may have been in youth or sometimes even lighter.

As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.

Expected complications

Most people experience some increased sensitivity to cold stimuli while undergoing this process.
Your teeth will continue to naturally age and darken following this procedure meaning most people will choose to top up the result in the future.

Common risks and complications

The extent to which your teeth will whiten cannot always be accurately predicted. The effect can be greater for some people than others.
Only tooth material will whiten so some fillings and crowns may look out of place afterwards meaning some people chose to then have those replaced.

Rare risks and complications

Allergic reaction to something used during the procedure.

Patient Signature(Required)

Date of Signature(Required)

Comments

This field is for validation purposes and should be left unchanged.