Patient information form
I, Hereby autthorize and direct Dentalzorg Dentistry and it’s staff to perform upon me with the dental treatment including necessary or advisable examination, rediographs
( X-rays), diagnostics, local anesthesia and any other treatment the dentist considers necessary to create betterhealth for my mouth.
In general terms, dental treatment may include but not limited to one or number of the following:
Administration of local anesthesia
Cleaning of the teeth and application of topical fluoride
Application of sealants to the grooves of the teeth
Treatment of diseased or injured teeth with dental restorations
The replacement of missing teeth with a dental prosthesis ( Crown, bridge, partials, etc )
Treatment of the canal or pulp chamber that lies in the middle of the tooth and its roots also known as
“endodontic” therapy or root canal treatment
RISK OF DENTAL PROCEDURES IN GENERAL
Included ( but not limited to ) are complications resulting from the use of dental instruments, drugs, medicines analgesics ( Pain killers ) anesthetics and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensations in the lip, tongue, chin, gums, cheeks, and teeth .Thrombophlebitis ( inflammation to a vein ) reactions to injection, change in occlusion ( biting ), muscle cramps and spasms. Tempomandibular jaw (TMJ) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues. Referred pain to the ear, neck and head nausea, allergic reactions, itching, bruises, delayed haling, sinus
complications and further surgery. Medications and drugs may cause drowsiness and lack of awareness and coordination, this it’s not advisable not to operate any vehicle or work for twenty-four hours or until recovered from its effects.
CHANGES IN TREATMENT PLAN
A treatment plan is based on the best evidence available during the examination. I understand that during treatment, it may be necessary to change and/or add procedure because of conditions found while working on the teeth that were not discovered during the examination or course of treatment.
I understand that i may experience hot and cold sensitivity, pain or discomfort following routine restorative procedures and that is usually temporary and should settle without further treatment. If in the event that my condition does not getting any better, I understand that i may need futher dental treatment, the most being root canal therapy.
CROWNS (CAPS), BRIDGES AND ONLAYS
I understand that sometimes it is not possible to match the color of artificial teeth with natural teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept permanent on until the permanent crowns are delivered. I realized the final opportunity
to make changes in my new crown or bridge (including shape, fit, size and color) will be before cementation. Once cemented, I understand that any changes in shape, fit, size or color wil incur additional charge.
I understand that i have the right to choose, on the basis of adequate information, from alternate treatment plans that meet professional standards of care By signing below, I consent to the general treatments and/or proposed treatment
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Adalat group was established in 1988 in Amsterdam, The Netherlands and since then has only grown to become one of the best professional dental organizations.
DentalZorg has three practices in the Netherlands; two in Amsterdam and one in Zaanstreek-Waterland regions, and two practices in the UAE، can you please reviews us in Google.