By signing this document, I authorize Dr. ___________________ and /or his/her associates to render any services deemed necessary or advisable in the treatment of my dental condition, including the prescribing and administration of any medically necessary anesthetic agents …
By signing this form, I am freely giving my consent to authorize my dentist and/or all dental associates involved in rendering any services he/she deems necessary or advisable to my dental treatment.
By signing this form, I am freely giving my consent to authorize Dr. David P. Gordon and/or all associates involved in rendering any services he deems necessary or advisable to treatment of my dental conditions, including the administration and/or
understand that the treatment of my dentition involves the placement of composite resin fillings, which may be more aesthetic in appearance than some of the conventional materials that have been traditionally used, such as silver amalgam or gold, may entail certain risks.
understand that the treatment of my dentition involving the replacement of SILVER AMALGAM FILLINGS OR COMPOSITE RESIN FILLINGS may entail certain risks. There is the possibility of failure to achieve the desired or expected results.
During the first appointment, the teeth are prepared and tooth colored filling material is placed on the front of the teeth and shaped to the desired form. The material is finished and polished to a life-like shine. A second polishing appointment may be necessary.
> > INFORMED CONSENT - Composite Filling Procedures I UNDERSTAND that dental treatment requiring COMPOSITE FILLING procedures, which I desire to have performed, include certain risks and possible unsuccessful results or procedural failure.
By signing this form, I am freely giving my consent to authorize Dr. Ericksen and/or all associates involved in rendering the services or treatment necessary to the existing dental condition, including the administration and/or prescribing of any anesthetic agents and/or medications.
Fillings are used to protect a sensitive surface of the tooth, to replace tooth structure, relieve pain, cover an eroded area and fill in a hole or space in the tooth structure. understand that care must be exercised in chewing after the placement of fillings, especially during the first 24 hours, to avoid breakage.
Consent for Fillings Dear Patient, We want to inform you of our policy regarding filling material and associated costs. We only do Composite fillings (white/tooth colored). We do not provide Amalgam (silver fillings). The advantages for composite fillings include but are not limited to: 1. Better esthetics 2. No Mercury 3.