Informed Consent for Treatment Please complete this Consent for Treatment form below. If you have any questions call us on (615) 915-6090. Patient name:(* required) First Last Patient date of birth:(* required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Informed Consent for Treatment of General Dental ProceduresI understand that I have the right to accept or reject dental treatment recommended by my dentist. Prior to consenting to treatment, I will read all the information provided below and consider the benefits, risks, alternative treatments, and option of no treatment. Exams: I understand that to be properly evaluated and provided current diagnoses, I must consent to receiving a thorough examination by a dentist. This may require study models and/or photographs in addition to clinical examination by the dental provider. I understand that no additional treatment shall be provided should I refuse to receive a dental examination. X-Rays (Radiographs): I understand that in order to have complete information to make an accurate diagnosis, the dental provider will require radiographs to be taken at dental visits. I understand that Michael D. Vaughan, D.D.S. practices according to the ALARA or “as low as reasonably achievable” principle and only takes x-rays when needed. In addition, Michael D Vaughan, D.D.S. utilizes advanced technology of phosphor plates and digital x-rays, which require significantly less radiation exposure than traditional radiographs. While radiographs may be safely taken if I am pregnant, I will notify staff if I elect to delay imaging until the next appointment. Benefits: more complete diagnosis of caries in between teeth, bone loss indicative of potential periodontal disease, and of the nerve and pulp tissue by viewing the roots of the teeth Risks: x-ray exposure to radiation (usually less than daily amount of background radiation) Local Anesthetic: I understand local anesthetic may be required to eliminate discomfort while receiving treatment and it may be administered by a doctor or registered dental hygienist. I have notified the providers in my intake form of any prior diagnosis of methemoglobinemia as well as any known ester (topical anesthetic, benzocaine, oragel), amide (rare) or sulfites (preservatives – methylparaben or metabisulfite) allergies and adverse reactions to anesthetics. Non-injectable anesthetic provided in the office is either 20% benzocaine (topical) or Oraqix, 50% lidocaine / 50% prilocaine (intrasulcular). Injectable anesthetic (usually lidocaine or articaine) provided in the office is typically mixed with epinephrine, which may cause sweating, shakiness, quickened heartbeat, dizziness, and/or anxiety. Benefits: localized anesthesia from treatment being performed, leading to safer care by the provider and comfort for the patient. Complications: numbness leading to accidental biting of cheek, lip, tongue resulting in swelling or discomfort, swelling, bleeding, infection, or discomfort at the site of injection; prolonged sense of numbness or lingering tingling sensation (most often temporary); jaw or muscle cramps/spasms; jaw joint discomfort radiating to head, neck, or ears, allergic reaction. Cleanings: I understand that the type of cleaning recommended will be determined by the examination performed, including periodontal charting and x-rays. Depending on the level of cleanliness, gingival inflammation, and/or bone loss, I may require a prophylaxis, full mouth debridement, and/or scaling and root planing. I authorize the use of floss, hand instruments, ultrasonic scalers, and polishing tools to remove plaque, tartar, and stains. I understand that disease intervention will require work on my part to foster healthy habits such as regular brushing, flossing, and cessation of tobacco use. I understand that my physiologic makeup is different from everyone else, and it is may be impossible to determine the results of healing. If I require antibiotics dose prior to cleaning, I will provide the necessary documentation from my primary care physician or request the medication from my physician. Prophylaxis: a preventive procedure that removes the bacterial biofilm and biotoxins caused by food (plaque and calculus) Full mouth debridement: is the removal of plaque and calculus that interferes with the dentist’s ability to perform an evaluation. This may need to be completed in conjunction with a prophylaxis or SRP Scaling/root planing (SRP): a “deep cleaning” may require local anesthetic to clean under the gums and along root surfaces. I understand that sensitivity is normal for a few weeks and gum recession is a part of healing. Often times, SRP treatment requires more frequent visits, known as "periodontal maintenance" to prevent further progression of periodontal disease. Benefits: removal of plaque, tartar, staining; reducing inflammation; reducing periodontal pocketing; preventing further bone loss that can lead to tooth loss; mitigating systemic effects of chronic diseases Risks: soreness, bleeding, temporary sensitivity, recession of gums, stretching of lips, corners of mouth If an SRP is recommended, and I refuse treatment, I will sign a Treatment Refusal form releasing Michael D. Vaughan, D.D.S. of all liability associated with my untreated condition. Restorative (Fillings, Crowns, Bridges): I understand that if decay is detected either clinically or radiographically, I will require a restoration in one of the following forms: filling, crown, or bridge. Fillings: I consent to restoration of my cavity with a filling. I understand amalgam (silver) fillings are not placed in this office and that composite (white) fillings may be tough to match the exact tooth color on stained teeth. I understand that increased sensitivity may be normal for 4-6 weeks and that I need to be gentle when chewing on teeth with fillings. I understand that if the decay is extensive, a crown or root canal may be indicated instead of a filling. Crowns (caps): I understand that a crown may be necessary if I have inadequate sound tooth structure to retain a resin white filling and full coverage requires my tooth to be shaved down. I understand that receiving a crown takes multiple visits and that I will receive a temporary for a few weeks while the crown is being fabricated in a laboratory. I understand that my temporary may come off easily and that I must be careful to ensure it is kept on until the permanent crown is placed. Should my temporary come off, I will notify Michael D Vaughan, D.D.S. and return to have it replaced. I understand that it is my responsibility to return within 3 weeks for permanent cementation and that delays may cause tooth movement or additional decay, which may necessitate a remake of the crown, and I will assume all financial responsibility associated with remake due to delayed cementation. I will be shown the final restoration and given the opportunity to approve or deny based on size, shape, fit, and color prior to cementation. I understand that final cementation is permanent, and that changes beyond that may be at my expense. Fixed partial denture (FPD): A “bridge” may be placed to fill any gaps between stable teeth. I understand that in order to qualify for a bridge, my teeth and gums must be in sound periodontal condition and cavity-free. I understand that receiving a bridge requires the adjacent teeth to be shaved down permanently and that the alternative procedure would be implant placement or leaving the space empty. I also understand that leaving an open space will ultimately result in movement of adjacent teeth into the empty space, which could adversely affect my periodontal health. Desensitizer (glutaraldehyde): I understand that to provide the best quality of care to patients, Michael D. Vaughan, D.D.S. uses a desensitizing agent to be used under all fillings and crowns. I authorize a non-staining desensitizing agent to be used to avoid sensitivity, but understand that in rare cases, patients have mild allergic reactions to the material (swelling, discomfort). I will notify Michael D. Vaughan, D.D.S. should I have any of these symptoms. Alternatives: no treatment or SDF (to buy time for definitive treatment). Please note that the treatment plans may change if an extensive period of time elapses after original diagnosis. Silver Diamine Fluoride (SDF): SDF has recently been FDA approved to treat teeth for hypersensitivity. It has been shown to arrest decay, and multiple treatments can reduce discomfort while prolonging the need for more invasive procedures (root canal or extractions). I understand that placement of silver diamine fluoride does not restore tooth form lost to decay and cavitated lesions will still need to be restored for optimal function. Benefits: reduce pain/sensitivity, arrests decay, can be used to “buy time” for necessary treatment Risks: esthetic concerns, stains decay black (tooth turns dark), possible temporary discoloration of gums and tissues Contraindications: allergy to silver, localized aphthous ulcers Root canal therapy (RCT): If a tooth is determined to be restorable and decay has extended past the hard tooth surfaces into the pulp tissue where the nerve resides, RCT will be necessary to save the tooth. I understand the alternative to RCT is to have the tooth removed and by not receiving any definitive treatment, I may be putting myself at risk for further infection. I understand that definitive treatment for "irreversible pulpitis" or nerve damage that may occur within a tooth that has a filling is to receive an RCT. If I agree to receive an RCT, I will be provided an additional consent listing out all risks and benefits and will get a chance to ask questions prior to treatment. I understand that for difficult cases, I may be provided a referral to have an outside specialist treat the tooth in question. Extractions (EXT): If a tooth is mobile due to significant bone loss or non-restorable due to decay, it may require either a simple or surgical extraction. I understand that I may elect to extract a tooth in lieu of definitive treatment options that can save the tooth (root canal, crown, filling). I may elect to do nothing or receive silver diamine fluoride to delay treatment until I have decided on a permanent solution. If I agree to receive an EXT, I will be provided with an additional consent listing out all risks and benefits and will get a chance to ask questions prior to treatment. I will discuss options for replacing the tooth with the doctor prior to extraction. Complete or Partial Dentures (Removable Prosthetics): Missing teeth may be replaced with a partial or complete removable denture and I understand that it can often take months to receive dentures due to necessary laboratory work. I understand that if I do not have adequate bone structure, I may require denture adhesive to retain dentures for ideal form and function. Complete dentures (CD): I understand that complete dentures may often require relines or adjustments after initial fabrication. Immediate dentures can be delivered upon extraction of remaining teeth, but will result in additional inflammation and discomfort. I understand that I cannot remove immediate dentures for the first 24 hours after extractions. I will notify Michael D. Vaughan, D.D.S. of any sore spots and return with the dentures for adjustment visits as needed. Removable partial denture (RPD, cast metal framework or transitional): I understand that the type of partial recommended is dependent upon my current periodontal condition. If I plan to proceed with a cast metal partial, I understand that caries control is prioritized and I authorize Michael D. Vaughan, D.D.S. to make any small grooves or adjustments to my existing dentition to ensure proper fit of partial denture. I understand that partials can also cause periodontally involved teeth to become more unstable. Benefits: regain form, some function, and esthetics Risks: suboptimal function, sore spots, altered speech, difficulty eating, immediate dentures (upon ext) may require additional adjustments and relines, are more painful, and often not included in the denture fee Alternative treatment: For some patients, implants or bridges may be viable options. Otherwise, I understand I can elect to receive no treatment and remain partially or completely edentulous, where lack of adequate support can cause additional shifting of teeth and progression of periodontal disease. Mild or Moderate Conscious Sedation: I understand that if I am slightly nervous, I can elect to use nitrous oxide gas for a nominal charge. I understand that I am more anxious, I may elect to receive mild or moderate sedation in the form of oral sedation, IM sedation, or IV sedation and will need to fill out an additional consent form as well as provide all necessary medication information prior to the appointment. I understand that I will require someone to accompany me during oral, IM, or IV sedation, as I will be unable to drive after my procedure. I will ask all the necessary questions ahead of time to arrive to a conclusion prior to procedure should any changes be made during the sedation. Nitrous Oxide (N2O): A colorless, slightly sweet gas used for mild anxiety. I understand that when inhaled, it can induce feelings of euphoria and mild sedation, and that I can continue to swallow, talk, cough, through the procedure. I understand the effects are mild and can be eliminated from the body when no longer administered. Benefits: safe, inexpensive, quick onset, can be titrated, can return to work and/or drive Risks: doesn’t work for everyone, can cause increased anxiety, hypoxia, overdose, dizziness, nausea Contraindications: pregnancy, mouth breathing, COPD, untreated B12 deficiency Changes in Treatment Plan: I understand that during treatment, it may be necessary to change or add procedures because of conditions discovered while working on teeth. The most common would be root canal therapy or extraction instead of a routine restorative procedure. I give permission to the dentist to make any and all changes or additions necessary to adequately diagnose and safely treat, including during sedation if I am unable to give informed consent at the time. I understand that medications or prescription medications given in or by the office are common. I have provided, to the best of my ability, accurate information regarding my medical diagnoses, medications, allergic reactions (itching, swelling, breathing difficulty), and adverse reactions (nausea, vomiting, headaches, drowsiness) to allow the dentist to provide me with the safest treatment possible. With this information, I am providing consent for dental procedures to be performed. I understand I will be provided an additional consent for more complicated procedures and be given the opportunity to ask any questions I may have regarding treatment. Should I choose no treatment, I hereby release Michael D. Vaughan, D.D.S. of all liability associated with consequences resulting from my diagnosis. By signing this form, I am freely giving my consent to allow and authorize Michael D. Vaughan, D.D.S. to render any general treatment necessary or advisable to my dental conditions for my own benefit or the benefit of my child or ward. SubmitDoes the patient have a legal guardian or conservator? Yes No Name of legal guardian or authorized representative?(* required) Name of corporate conservator company if applicable? Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Consent?(* required) Yes No E-mail address:(* required) Please sign(* required) Reset signature Signature locked. Reset to sign again Important: You consent to sign this document electronically.