I request and authorize Dr. Karen Barwick and/or associates or assistants of her choice to perform the following treatments/procedure(s):
I further request and authorize the taking of oral dental Images and the use of such anesthetics as may be considered necessary and/or advisable by the doctor responsible for my/the patient’s treatment.
I have had explained to me, and I have has sufficient opportunity to discuss my/ the patient’s dental condition/problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment, compared with alternative approaches and/or no treatment.
The usual and most frequent risk or complications occurring from the planned treatment and procedures also have been explained to me. These risks include, but are not limited to, the possibility of pain or discomfort during the following treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a transient or permanent temporomandubular joint (TMJ) disorder, opening of or displacement of a tooth or portion thereof into the sinus (a normal cavity situated about upper teeth) or other anatomic location requiring additional surgery to close the opening or recover the tooth structure, temporary or permanent numbness, and allergic reactions.
I understand that during the course of my/the patient’s dental treatment something unexpected may arise that may necessitate procedures in addition to or different from those planned. I am aware that then practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made concerning the results of the treatment that I/the patient will receive.
All of my questions have been answered to my satisfaction, and I consent to the treatment and procedures prescribed for me/the patient.
I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent that treatment and procedures have already been performed or initiated.
I confirm that I have read this form or it was read to me. And that all blanks were filled in and all inapplicable paragraphs, if any, were crossed out before I initial my agreement/acknowledgement below.