INFORMED CONSENT FOR COMPOSITE FILLINGS / RESTORATIONS TOOTH / TEETH TO BE TREATED

I understand the treatment of my dentition involving the placement of composite resin fillings may entail certain risks. There is also the possibility of failure to achieve the results which may be desired or expected.

Sensitivity of Teeth: Often after preparation of teeth for the placement of any restoration, the prepared teeth may exhibit sensitivity. This sensitivity may be mild to severe. This sensitivity may last for a short or long period of time. If such sensitivity persists or lasts for an extended period, I agree to notify the dentist as this may be a sign of more serious problems. This may result in the need for additional treatment including but not limited to an indirect pulp cap, root canal therapy or extraction

Risk of Fracture: Inherent in the placement or replacement of any restoration is the possibility of small fracture lines in the tooth structure. Sometimes these fractures may not be apparent at the time of removal of the tooth structure and/or the previous filling and placement or replacement but may manifest later. This may result in the need for additional treatment including but not limited to root canal therapy and crown or possible extraction.

Necessity of Root Canal Therapy: When fillings are placed or replaced the preparations of the teeth for fillings often necessitate the removal of tooth structure adequate to insure the complete removal of the diseased or otherwise compromised tooth structure. This exposes sound tooth structure for the placement of the restoration. At times, this may lead to exposure or trauma to the underlying pulp tissue. Should the pulp not heal, which often time is exhibited by extreme sensitivity or possible abscess, root canal therapy or extraction may be required. If root canal therapy is required, a crown may be necessary.

Breakage, Dislodgement, or Bond Failure: Due to extreme biting pressures or traumatic forces, it is possible for composite fillings or aesthetic restorations to be dislodged or fractured. The resin-enamel bond may fail resulting in leakage and recurrent decay. The dentist has no control over these factors. I understand it is my responsibility to notify this office should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of composite fillings and have received answers to my satisfaction. I do voluntarily assume any, and all possible risks, including risks of substantial harm which may be associated with any phase of this treatment in hopes of obtaining the desired and/or satisfactory results. By signing this form, I am freely giving my consent to the doctor and/or all associates and assistants involved in rendering any services he/she deems necessary or advisable to treatment of my dental conditions, including the administration and/or prescribing of any anesthetic and/or medications.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post-treatment instructions have been explained to me.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.