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Periodontal treatment consent
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As with all medical procedures, there are risks and potential complications associated which you must be aware of before you proceed with treatment:
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Periodontal treatment is not 100% successful all of the time, even if all parts of the procedure go as planned. Therefore some teeth that have undergone this procedure will require further treatment or may require extraction.
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Tooth Preparation procedures consent
Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows:
I have been given all treatment options including no treatment, extraction(s), and restorations and have opted for: filling(s)/ Crown(s)/ Bridge(s) / Veneer(s) or………
I understand that having fillings, crowns/ bridges or veneers carries certain risks and these are outlined as follows:
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- Crowns/veneers/bridges and fillings are not always 100% successful, even if all parts of the procedure going as planned. The tooth may not have enough strength left prior
to this procedure for good long term results. Decay and any previous work may have already irritated the nerve which could result in toothache in the future. Therefore some teeth that have undergone this procedure will require root canal treatment in the future, or may require extraction.
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Teeth Whitening Consent
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Extraction Consent
I understand that there may be an alternative to the extraction of teeth. After considering the various options discussed with me however, I have chosen an extraction. I understand that there are sometimes complications that can occur, despite all efforts to the contrary as a result of the extraction(s) which include but are not limited to:
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I agree to proceed with the recommended extraction(s).
Date Format: DD slash MM slash YYYY
Denture Consent
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I agree to proceed with the recommended extraction(s).
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Root Canal Patient Consent Form
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Informed consent to treatment
Dental Implant Pre-treatment Consent
The options were discussed in detail with you for replacing the missing teeth which included:
(Tick boxes if discussed with patient)
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We discussed the risks and benefits of the implant treatment options in detail as follows:
Platinum Dental plan details:
Botulinum Toxin Therapy for Wrinkle Correction
What is Botulinum Toxin?
Botulinum toxin is a bacterium that blocks the release of acetylchline, the substance responsible for transmitting electrical impulses that elicit muscle contraction. In medicine, botulinum toxin is injected directly into hyperactive muscles. It has been safely and effectively used for treatment of strabismus (cross-eye) and blepharospasm (lid spasm) since the early eighties.
How does botulinum toxin work?
Hyperactivity of the facial expression muscles often results in the development of deep frown lines, forehead lines and/or crow’s feet. Injecting botulinum toxin into the affected area temporarily paralyzes the underlying muscles responsible for wrinkling, giving the face a more relaxed and pleasant appearance. The wrinkles become smoother or disappear altogether.
When and how long does botulinum toxin work?
The initial effects of treatment become visible within 48 to 72 hours. The maximum effect is reached in about 1 to 2 weeks.
Your facial expressions will become more relaxed but by no means mask-like. The overall result is very natural.
The effect of treatment generally lasts 4 to 6 months. Re-treatment is then required.
Potential adverse effects (side effects)
Botulinum toxin injection is generally a safe and effective treatment method. Nevertheless, certain side effects can occur but, like the intended treatment effects, they are mostly reversible.
At this appointment, you will be informed about the potential side effects of botulinum toxin therapy, contraindications to therapy, and potential drug interactions.
Potential side effects
- Bruising or swelling at the injection site
- Slight feeling of nausea
- Tiredness, pain in the arms and legs
- Temporary drooping of the eyebrow or upper eyelid
- Brief visual disturbances
- Dryness of the eyes
- Skin rash
- Itching
- Allergic reaction
- Dry mouth
- Muscle atrophy
Contraindications
- Pregnancy
- Breast-feeding
- Myasthenia gravis
- Lambert-Eaton syndrome
- Blood coagulation disorders
Drug interactions
Drug interaction can occur when botulinum toxin is used concomitantly with other medications. Since these medications can alter the effects of botulinum toxin, you must ensure that your doctor is aware of any current medications you are taking, especially
- Aminoglycoside antibiotics
- Anaesthetics
- Muscle relaxants