Parrock consent forms | Dentist In Kent

Consent forms

Your Details
Name*
Prefix First Last
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DOB*
Treating Dentist Name
Consent Form Type*
- Tooth Preparation Procedures consent
- Teeth Whitening Consent
- Extraction Consent
- Dentures Consent
- Root Canal Patient Consent
- Periodontal Treatment consent
- Dental Implant Consent
- Botulinum Toxin Therapy for Wrinkle Correction
- X-Ray and Ct scan consent
Periodontal treatment consent
Consent*
We have discussed your diagnosis of periodontal gum disease and you understand that you need a course of periodontal treatment to stabilise your condition.*
Consent*
Periodontal disease is an infection that affects the gum, ligaments and the bone that support the teeth.*
Consent*
Periodontal treatment involves a number of appointments, each course of periodontal treatment is tailored to meet your individual needs. The treatment involves cleaning above and below the gums. The long term aim is to prevent the further development of gum disease and to prevent the loss of any teeth.*
Appointments may involve:*
1: Pocket charting and measurement of the bone levels
Appointments may involve:*
2: Oral hygiene instruction*
Appointments may involve:*
3: Deep cleaning of the tooth surface below the gum*
Appointments may involve:*
4: Medicating any deep pockets*
Appointments may involve:*
5: Laser therapy*
Consent*
By using local anaesthetic and /or sedation where necessary, we take great care in making the treatment as comfortable as possible.*
Consent*
Home care (by the patient) is vital to the success of the treatment.*
Consent*
The Hygienist/Dentist will design a home care programme with you, explaining the use of different hygiene aids suitable to your diagnosis.*
Consent*
As periodontal disease is an irreversible chronic condition, regular maintenance appointments are essential in preventing further bone and tooth loss.*
Consent*
If there is no significant improvement, it may be necessary to refer you to a periodontist (gum specialist). The periodontist will re-assess your oral health and advise you on further complex treatment which may involve surgery of the gums.*
As with all medical procedures, there are risks and potential complications associated which you must be aware of before you proceed with treatment:
Expected complications
Numbness lasting a few hours.
Soreness of the gums lasting a few days.
Requirement for maintenance cleaning in the future.
Common Risks and complications:*
Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:*
Some teeth with have increased sensitivity for some time after the procedure.*
Common Risks and complications:*
Inability to clean the tooth well enough to control the periodontal disease.*
Common Risks and complications:*
Cosmetic changes to the gums.*
Rare Risks and complications 1:*
Trauma to the tissues under the tooth including bone, sinus, nerves supplying the other teeth etc.
Rare Risks and complications 2:*
Allergic reaction to something used during the procedure.*
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.
ConsentAlternative options:*
1- Referral to a specialist in this field who may be able to treat the tooth better via a microscope and specialist equipment.
ConsentAlternative options:*
2- Treating the tooth in a different way, such as extraction.*
ConsentAlternative options:*
3- Refusing any treatment, this will result in a high risk of further gum strength ultimately leading to the loss of some teeth.*
Do you consent to the treatment : Periodontal Consent Form*
- Yes
- No
Informed consent to treatment: Periodontal Consent Form*
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Periodontal Consent Form*
- I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Signature
Date of Signature
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:
Please Read and Tick*
In order to make space for the filling/ crown /bridge/ veneer we will be reducing the amount of natural tooth structure. Our preparation will be done as minimal as possible to give you the best aesthetics and strength in your filling/ crown/ bridge/ veneer.*
Please Read and Tick*
In reducing and roughening the tooth surface it is possible that irritation of the nerves may occur and this may cause sensitivity after the tooth is prepared and even after the restoration is completed. If it continues I am aware it may be necessary to perform root canal therapy on this tooth or in a worst case scenario remove the tooth, this may incur an additional fee.*
Please Read and Tick*
Chipping, breaking or loosening of the filling/ crown/ bridge / veneer may occur at any time following the placement. Many factors may contribute to this happening such as chewing of excessively hard material, traumatic blows to the mouth, grinding or clenching of teeth and other conditions over which the dentist has no control.*
Please Read and Tick*
Appearance: Every attempt possible will be made to match and co-ordinate both the shape and colour of the filling/ crown/ bridge/ veneers which will be placed to be cosmetically pleasing to you. However there are some differences which may exist between that which is natural and which is artificial, making it impossible to have the colour and or shape to match your natural teeth.*
Please Read and Tick*
Longevity: It is impossible to place a specific time criteria on the length of time that fillings/ crowns/ bridges/ veneers will last.*
Please Read and Tick*
If you have any issues with any work carried out here, we recommend that you call us immediately and give us the opportunity to rectify any issues and address any concerns you may have.*
Expected complications 1:*
Numbness lasting a few hours.
Expected complications 2:*
Soreness of the gums lasting a few days.*
Common Risks and complications:*
Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:*
Some teeth with have increased sensitivity for some time after the procedure.*
Common Risks and complications:*
Darkening of the root of the tooth depending on the material used.*
Common Risks and complications:*
Inability to return the tooth to a perfect shape which could result in the tooth being difficult to look after.*
Rare Risks and complications:*
Removing tooth material to make space for a crown/veneer/bridge/filling can irritate the nerve inside the tooth, sometimes leading to the nerve dying and causing toothache.
Rare Risks and complications:*
Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.*
Rare Risks and complications:*
Allergic reaction to something used during the procedure.*
Expected complications*
Numbness lasting a few hours
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.
Alternative options:*
Referral to a specialist in this field who may be able to treat the tooth better via a microscope and specialist equipment.
Alternative options:*
Treating the tooth in a different way, such as extraction.*
Alternative options:*
Refusing treatment, but this will result in a high risk of fracture/ pain or infection from this tooth.*
Do you consent to the treatment*
- Yes
- No
Informed consent to treatment: Tooth Preparation procedures consent*
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
Informed consent to treatment: - I choose to refuse the advised treatment Tooth Preparation procedures consent*
- I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Signature
Date of Signature
Teeth Whitening 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;*
The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or are aware of an adverse reaction to this ingredient, please do not proceed with this treatment.
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;*
As with any treatment there are benefits and risks. The benefit is that teeth can be whitened fairly quickly in a simple manner. This method is the most cost effective and successful method currently available. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to whiten teeth is safe. There is new research indicating the safety for use on the soft tissues (gums, cheek, tongue and throat). The long-term effects are as yet unknown. Although the extent of the risk is unknown, acceptance of treatment means acceptance of risk.*
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;*
There have been instances where damage occurring to some teeth can cause extreme pain and require root canal treatment at a further cost to you, and could ultimately result in extraction of these teeth. This is very rare, you will generally get ulcers, soreness and irritation to the gum.*
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;*
The amount of whitening colour improvement varies with the individual and cannot be guaranteed. Most patients achieve a change within approximately 2 - weeks. It is important to reduce the consumption of tea, coffee, red wine, berries and curries during or after treatment for at least 1 month, and follow all the advice given by your dentist and in the advice sheet provided.*
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;*
It is advisable not to smoke during the course of whitening treatment and for at least 5 - 8 weeks afterwards.*
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;*
You may notice sensitivity after a few days of treatment. This is perfectly normal. If this should occur you can refrain from using the whitening treatment for 3 to 4 days, or follow the advice given to you by your dentist.*
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;*
Do not use the whitening treatment if you are pregnant. There have been no adverse reactions, but long-term clinical effects are unknown.*
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;*
You can wear the trays overnight or for a few hours during the day (e.g. whilst watching television in the evening).*
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;*
After the desired amount of tooth whitening has been achieved, you may be requested to return to your dentist for a review appointment to check the results/shade achieved. It may be necessary to do a top-up treatment in 4 to 6 months or more, depending on the amount of staining and your diet.*
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;*
All existing restorations such as fillings, veneers and crowns will not whiten and these may need to be replaced for cosmetic reasons after teeth whitening at further cost to you and you accept this.*
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;*
If you are having any restorative work such as crowns, cosmetic fillings, veneers, bridges and implant treatment, teeth whitening must be stopped 2 weeks prior to any impressions and shade taking appointment to allow the teeth colour after teeth whitening to stabilise. Otherwise the final restorations will appear too white and may need replacing at further cost and time to you. You accept these risks and costs.*
Informed consent to treatment:*
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment. I agree to proceed with the recommended teeth whitening.
Signature*
Date of Signature
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:
Please read and tick*
I have informed my dentist of any underlying medical conditions.*
Please read and tick*
Afterwards, the area may be sore and swollen, there is also a risk of infection, dry socket, bruising that can in rare cases extend as low as the neckline and bleeding after the tooth has been extracted.*
Please read and tick*
I understand that after extraction, some bone will be lost in this area and may effect the other teeth. I have been advised on what can be done to minimise this.*
Please read and tick*
The jaw muscles can be sore and stiff afterwards.*
Please read and tick*
The area around the extraction site will be numb during and after the procedure, please avoid biting your lip and consuming hot food.*
Please read and tick*
In cases of extracting the lower wisdom teeth, there is a risk of temporary or permanent numbness in the lower lip.*
Please read and tick*
In cases of extracting some upper teeth, there is a risk of OAF (Oral Antula Fistula). Your dentist will explain this to you if applicable.*
Please read and tick*
During an extraction, there is a small chance of damaging near by teeth.*
Please read and tick*
There is a chance of the tooth breaking whilst trying to extract it, your dentist will endeavour to remove the remaining tooth, however may need to refer you to the hospital if it is in your best interests.*
Please read and tick*
Stitches may be placed where clinically necessary to aid healing.*
Please read and tick*
I have been informed of all my options for replacing the space once the tooth has been extracted.*
Please read and tick*
I further understand that this procedure can also be performed by a specialist dentist and request that this treatment is performed at Parrock Dental by a general dentist.*
Please read and tick*
The dental treatment to be carried out has been explained to me and I understand what the procedure entails.*
Please read and tick*
I consent to the extraction proposed (including anaesthetic and any x-rays that need to be taken during the process).*
Expected complications:*
Numbness lasting a few hours.
Expected complications:*
Soreness, numbness and localised swelling lasting up to a week.*
Common Risks and complications:*
Trauma to other parts of the mouth, including teeth, gums, cheek and tongue etc.
Common Risks and complications:*
Prolonged post operative pain caused by poor healing or infection.*
Common Risks and complications:*
Fracture of the tooth during the procedure which can lead to a minor surgical proceeding being needed or a piece of the tooth being left because it cannot be removed.*
Rare Risks and complications:
Trauma to the tissues under the tooth including bone, sinus, nerves supplying the other teeth etc.
Rare Risks and complications:
A communication (hole) between the mouth and the sinus.
Rare Risks and complications:
Displacement of part of the tooth into the sinus.
Rare Risks and complications:
Allergic reaction to something used during the procedure.
Alternative treatment options:*
1- Referral to a specialist in this field who may be able to treat the tooth better with the use of specialist equipment etc.
Alternative treatment options:*
2- It may be possible to save the tooth with root canal treatment.*
Alternative treatment options:*
3- Refusing treatment, but this will result in high risk of further pain and infection from this tooth.*
Do you consent to the treatment : Extraction Consent Form*
- Yes
- No
Informed consent to treatment: - Extraction Consent
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
I agree to proceed with the recommended extraction(s).
REFUSE Informed consent to treatment: Extraction Consent Form*
- I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision. I refuse the above treatment and understand the possible consequences.
Signature
Date - Signature
Date Format: DD slash MM slash YYYY
Denture 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;*
The production of a denture is a procedure to create a removable prosthesis which is custom made for the individual to replace one or more missing teeth. I understand that there are alternative treatments to a denture such as dental implants to improve function and have been given that option.
As with all dental procedures, there are some risks and potential complications which you must be aware of before consenting to proceed with the treatment:*
Dentures are a removable prosthesis that do not work exactly like natural teeth. They can be made of metal or plastic and clasps and rest seats to hold them in the mouth depending on the design by your dentist.
Please read and tick*
Dentures must be removed for cleaning and kept out of the mouth during the night.*
Please read and tick*
It is common that dentures (whilst in the mouth) can move or become dislodged whilst talking or eating, and food can get trapped/stuck underneath them.*
Please read and tick*
Dentures can require adjustments, relining or remaking in the future due to changes in the shape of the gum changing over time.*
Please read and tick*
Thorough denture hygiene and oral hygiene is required to keep your mouth healthy when wearing a denture.*
Common risks and issues with dentures:*
Dentures can rub on the gums and cause ulcers, pain and discomfort.
Please read and tick*
Some dentures can put additional stress on the remaining/adjacent teeth, fillings or crowns and can lead to further work being required in the future. Dentures attract more bacteria in the mouth and you may be at a higher risk of gum disease and tooth decay which can result in further treatment being required or tooth loss.*
Please read and tick*
You may require new dentures to be made in the future due to further tooth or gum loss, poor fit or further work being required at a further cost to you.*
Please read and tick*
Temporary dentures will not have the best strength, appearance and bite and will require a replacement in the future, at a further cost to you.*
Please read and tick*
Dentures can be lost or broken resulting in further cost to mend or remake and also time with out denture whilst it is in the lab.*
Please read and tick*
Dentures are not always successful, even if all stages of the treatment go as planned. You are paying for the dentist time and laboratory costs. If you require additional treatment it will be done at an additional cost to you.*
Please read and tick*
Some people may not get on with dentures, even if they are technically sound and fit perfectly. The patient may then wish to replace the missing teeth in an alternative way.*
Alternative options to replace missing teeth:
1) Referral to a specialist in this field.
Please read and tick
2) Replace teeth with dental implant/s or bridgework.
Please read and tick
3) Take no action and leave the spaces as they are.
Please read and tick*
I understand that once I have completed my final try in appointment and my work is sent to the lab in preparation for my final fit appointment, no changes can be made to the restorations past this point. I have confirmed I am happy to proceed. If, in the event that I am unhappy with the restorations once I have my final fit, I will be liable to cover the costs of the lab fees and surgery time incurred, and any further costs incurred to make any changes, should I request a refund or any modifications.*
Do you consent to the treatment : Denture Consent Form*
- Yes
- No
Informed consent to treatment: - Denture Consent form
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
I agree to proceed with the recommended extraction(s).
REFUSE Informed consent to treatment: Denture Consent Form*
- I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision. I refuse the above treatment and understand the possible consequences.
Signature
Date - Signature
Date Format: MM slash DD slash YYYY
Root Canal Patient Consent Form
Root canal treatment has been proposed and agreed with you. 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;*
The alternatives to root canal treatment are; to not have any treatment, or to remove the tooth/teeth and you are not keen on those options.
Please read and tick*
Often a root canal is done to save the tooth when it becomes painful or swollen, due to infection.*
Please read and tick*
It can take up to 1 or 2 visits to clean out the root system, in some cases more.*
Please read and tick*
Pain and swelling can persist for a few days after each appointment or after completion. Occasionally the tooth may remain feeling different to how it was.*
Please read and tick*
After the root canal treatment is competed a crown is recommended in weak teeth and back teeth to prevent the risk of tooth fracture.*
Please read and tick*
Root filled teeth are more likely to break than non root filled teeth which is why we recommend a crown as soon as possible. If the tooth breaks extensively it may not be restorable, requiring removal.*
Please read and tick*
Not all root canal treatments succeed; the success rate ranges from 60-80% on average. Re-root treatments are more complex with a higher risk of failure.*
Please read and tick*
You may need re-treatment or the tooth may need to be removed if pain or swelling persists after treatment is completed.*
Please read and tick*
With your consent you may be referred to a specialist if problems cannot be resolved, this will incur an additional fee.*
Please read and tick*
Strong chemicals such as hypo chloride (mild bleach) are required to disinfect the tooth and with this are associated risks, such as burns, pain and discomfort, which are not common, and reduced with great care taken.*
Please read and tick*
Breakage of files during the procedure is a risk and can happen, which could lead to failure.*
Please read and tick*
Not all teeth are the same, sometimes it may not be possible to find, clean and fill every root canal perfectly.*
Please read and tick*
Root canal treatment is not always 100% successful, even if all aspects of the procedure go according to plan. Therefore some teeth which have undergone this procedure may need to have the RCT re done, or may need to be extracted.*
Please read and tick*
It is important to keep the treated teeth clean or the root canal may fail. We recommend at least 6 monthly visits to a hygienist.*
Informed consent to treatment
Do you consent to the treatment*
- Yes
- No
Informed consent to treatment: Root Canal Patient Consent
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Root Canal Patient Consent
I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Signature
Date of Signature
Dental Implant Pre-treatment Consent
Treatment procedure proposed
Additional procedures
- Extraction
- Grafting
- Temporary restoration
Treatment options, advantages and disadvantages:

The options were discussed in detail with you for replacing the missing teeth which included:
(Tick boxes if discussed with patient)
- 1. No treatment and accept situation as it is including possible poor appearance and chewing-this was not an option for you as you requested replacement to improve your chewing and / or appearance for more confidence smiling.
- 2. Restorative options The remaining tooth was agreed to be restorable with a guarded to poor prognosis and we agreed to remove it.
- 3. An Acrylic denture. I advised this is removable, can compromise function as it can be loose and sore to gums when eating, difficult for some patients to tolerate due to bulk or gag reflex, may need to use adhesive, further teeth can be added, removable and can be bad for gums and adjacent teeth as accumulates plaque which can cause gum disease and decay of adjacent teeth, ongoing costs discussed as may need to be replaced regularly. You did not want this option as you wanted a fixed option.
- 4. A Chrome denture -This is chrome/metal at the back, removable, more tolerable, stronger and less palatal coverage than acrylic dentures, can have better retention with clasps and rest seats, further teeth can be added only if designed for this, lighter, costs more, more hygienic than acrylic). You did not want this option as you wanted a fixed option long term.
- 5. Fixed bridgework- we discussed that it would be fixed, can be done relatively quickly compared to implants, relies on adjacent teeth which need extensive preparation, periodontal/gum status must be excellent, preparation of teeth has several risks- risk of devitalisation, debond risk, risk of fracture of remaining tooth which require extraction if extensive, risk of gum recession and poor appearance, costs similar to dental implant tx. You did not want this option due to the risks and damage to adjacent teeth.
- 6. Adhesive (sticky) bridge work- this is relatively simple and quick to make, very conservative and has been shown to fare well when the load is low long term, there is a risk of de-bonding , the greyness of the metal wing can show through teeth giving a poor appearance, the cost is similar to other bridgework . You were not keen on this option long term due to the risk of de-bonding. But you may consider this if you require a temporary restoration.
- 7. Dental implant treatment: We discussed that this is usually fixed, independent of other teeth, requires certain criteria to be met i.e. sufficient bone , higher short term costs, only option other than healthy teeth that can maintain the jaw bone and prevent the mouth from sinking in over time. It has a long lasting long-term prognosis to replace missing teeth in many good quality studies, it is an expensive option, has a long treatment time, requires adequate bone volume. There are possible risks of damage to anatomical structures where the implant is placed- to the upper jaw sinus in the top back regions, in the lower back region the risk of damage to lower jaw nerves supplying the lower lip and chin areas and temporary nose bleeds and altered sensations in the top front region. A Ct scan is required in most cases for accurate planning and assessment of bone volume for implant placement and anatomical structures. The scan may show it may not be possible to place implants and you may require another option. Also we discussed a higher risk of failure if immediately placed at time of extraction or immediate loading, Also the possibility you may need a bone graft of pig and cow origin or from elsewhere in your mouth as with an immediate implant or where there is bone loss or a thin ridge or when infection present. You may require a soft tissue graft from the palate if the gum is thin or recedes. Also there is a long term risk of gum and bone loss over time exposing the metal which may require further tx at further cost to you for aesthetic reasons and the possibility of implant loss or failure over time which may need replacing at further cost and time to you. There is a higher risk of these in high risk patients who smoke, have poorly controlled diabetes, who grind or overload there teeth, who do not attend regular to get their mouth checked by our practice after treatment at the suggested recals. The implant is guaranteed for 1 year after placement and has been found to have a 10 year survival of 95+% in good quality studies in most healthy adults who do not have any high risk factors and who attend for maintenance tx by the dentist every 6 months and hygienist treatment every 3 months at our practice as advised from thenoutset. The restoration and components attached to the dental implant may loosen or fracture and may need tightening, repairing, refixing or replacing over time at further cost and time to you.
After a detailed discussion of all these options you wished to go for dental implant treatment
After a detailed discussion of all these options you wished to go for dental implant treatment as you wanted fixed teeth without grinding and damaging the adjacent teeth or any risks of debonding as with adhesive bridges.
Bone loss and possible grafts option discussion*
We discussed where the teeth have been missing, broken or infected and also the area/sites after extraction as well as cases of thin biotype gum and bone are at risk of some continual bone and gum loss over time even though there may be adequate bone for implant placement this can effect the final and long term appearance of the final restorations making them look longer than ideal and also lead to bone loss in the area over time exposing the metal of implants, posts and the final restorations.
Bone loss and possible grafts option discussion*
To correct this may require the use of pink porcelain material to mimic lost gum and you had no objection to this.*
Bone loss and possible grafts option discussion*
In areas or cases where the gum is thin there is a higher risk of gum recession sometimes showing the metal components or the teeth appearing longer than the adjacent teeth. To reduce this as best as possible a gum graft (connective tissue graft may be required from your palate and placed in the site. The donor site may be quite sore during the healing. You accepted this if required.*
Bone loss and possible grafts option discussion*
To reduce bone loss risk as much as possible we discussed options including replacing any lost bone for optimum aesthetics with a bone graft using your own bone (autogenous) or a guide tissue regeneration procedure with material of pig and cow origin. I advised you to an autogenous bone graft was considered the gold standard for the most predictable result, however due to the additional morbidity associated with this procedure we agreed to proceed with the alternative guided bone regeneration procedure where required using material of pig and cow origin such as BioOss and BioGuide or a synthetic alternative such as Ethoss . You advised me you had no issues using these materials and consented to their use.*
Bone loss and possible grafts option discussion*
The patient also accepts the risk that the gum and bone loss may still occur over time exposing metal of implants, post or restoration or that the final restorations may look longer or shorter than adjacent teeth in the final restoration-they accepted if this arises they may require further treatment for aesthetic reasons at additional cost and time to them.*
Bone loss and possible grafts option discussion*
We discussed use of non metal/metal free components but due to the strength we agreed to use metal reinforced restorations and metal posts to reduce long term risks of fracture but accepting over time if the gum recedes these may become visible requiring further tx for aesthetic reasons at additional cost.*
Bone loss and possible grafts option discussion*
The patient also accepts the possible risks we discussed of the grafts occasionally getting infected which may also cause implant failure and which can extend the treatment time and also lead to further bone loss which can lead to a poorer aesthetic final result or rarely implant failure.*
Risks and benefits of treatment discussed as follows:
We discussed the risks and benefits of the implant treatment options in detail as follows:
- • There are specific HIGH RISK FACTORS associated with high failure of dental implants and also natural teeth including parafucntional habits such as grinding and clenching and biting foreign objects, diabetes especially poorly controlled, smoking, gum disease and Bisphosohonate medication and other possible medical or specific bone conditions which could adversely affect the health of your gums and bone supporting your teeth and dental implants. Good clinical studies have shown approximately 50% less success with these conditions and habits compared with healthy individuals who do not have any risk factors especially who smoke, have diabetes or grind their teeth. We cannot guarantee the success of your dental implant treatment if you have any of these high risk factors or conditions as there is an unknown element that could lead to their failure which you accept and may lead to the need for further treatment requiring further normal costs and time. You accepted these risks. Our personal experience is a very high percentage of patients requiring dental implant treatments due to tooth loss or missing teeth smoke or suffer from at least one of these conditions or habits and we routinely treat them satisfactorily with dental implants.
- • Immediate implant placement after any tooth extractions would only be possible if the sockets and bone are healthy after careful extraction otherwise we will need to leave the area up to 6 months to heal with or without a temporary restoration.
- • For immediate implant cases we advise some graft material is used of pig or cow origin to reduce bone and gum loss in time.
- • Also we agreed to consider immediate loading of the implants only after careful assessment deems it suitable and if good primary stability of implants is achieved and a favourable occlusion with reduced overloading / grinding risk is present. Otherwise we agreed not to do this where there is a higher risk of failure and consider placing healing abutments over the implants or leaving the implants under the gum to heal and leave the gaps un-restored or restore them with a temporary restoration such as a denture or adhesive bridge where suitable on assessment.
- • The patient accepts there is a higher risk with immediate placement and loading of implant failure and complications requiring further treatment incurring further normal costs and time.
- • We also discussed the risks of placing lower posterior implants including permanent and temporarily IDN nerve damage and numbness sensation of the lower lip and chin/cheek in that area. The risks as we discussed are reduced with implant planning and placement using an accurate CBCT scan and placing shorter dental implants.
- • Also we discussed the risks of damage to adjacent teeth when placing dental implants.
- • Also we discussed the risks of placement of dental implants in the top front area including perforation of the nasal floor which could lead to temporary nose bleeds and altered sensations which usually resolve by themselves.
- • Also we discussed the risks of perforation of the upper jaw sinuses for upper posterior areas which could lead to acute or chronic symptoms including sinusitis and pain swelling and bruising which could lead to implant and any graft failure. Some of the complications may require specialist treatment separate to dental treatment at the practice. The risks as we discussed are reduced with implant planning and placement using an accurate CBCT scan and placing shorter dental implants.
Restorative phase
- • The final restoration work will usually start after the implants have healed or sometimes sooner. This is usually 4-6 months after implant surgery and involves several appointments before the final work is fitted. (Usually 2-6 appointments or more depending on the complexity.)
- • We always aim for the final restoration to be retained to the implant by a screw if possible so it can easily be tightened and accessed if required. If this is not possible for function or aesthetics it will be glued to the implant post by a temporary or permanent cement.
For full jaw or mouth work such as all on 4/ all on 6 treatment:
- ● In full Jaw and mouth dental implant work the final restoration takes some time to settle in for the tongue, cheeks and lips and speech such as lisping to adjust and patience is required during this adjustment phase which can take 6 to 12 months from being fitted.
- ● We design the final fixed full jaw bridgework if fitted to have a gap between it and the gums for cleansibility and hygiene of the implants to avoid failure. This may take some adjustment as food may accumulate but it is easy to remove with an airflosser if advised and tepe brushes as will be shown. Any altered senstion to your tongue and altered speech will take time to adjust to usually upto 6 to 12 months from being fitted.
- ● The final bridgework material can be metal-ceramic or metal-acrylic and both have their advantages and disadvantages.
- ● Metal- acrylic bridges are very pleasing in appearance and softer to the bite and jaw joint. They can be more prone to fractures and breakages being softer than metal-ceramic bridges especially in people who grind their teeth however they are easy to repair and not as costly as metal- ceramic bridgework. You would need to wear the first temporary bridge made for you during the repair period.
- ● They can also stain excessively over time requiring polishing and after a few years an overhaul of the acrylic on the bridge may be required which can be costly.
- ● Metal ceramic bridges have the best appearance and are usually stronger and thinner than metal acrylic bridges. However they are at risk of chipping and fracturing which is very costly to repair in the lab and you would need to wear the first temporary bridge made for you during the repair period.
- • I understand that once I have completed my final try in appointment or approved the appearance of the final teeth e.g. in temporaries, and possibly wax try in stage, my restoration work is sent to the lab for fabrication in preparation for my final fit appointment. No changes can be made to the restorations past this point. I have confirmed I am happy to proceed. If, in the event that I am unhappy with the restorations once I have my final fit, I will be liable to cover the costs of the lab fees and surgery time incurred, and any further costs incurred to make any changes, should I request a refund or any modifications you accept these costs.
Fitting of final implant restorations and dental implant health discussion
- • We discussed the fitting and hygiene around the implants. I advised there is a low risk of the failure of an implant after the first year of function as long as you do not have any high risk factors and your health both general and around the implants is maintained and no excessive forces are exerted. The dental implants are guaranteed by the practice in patients with NO HIGH RISK FACTORS for the first year from placement after which time all normal fees apply for any further treatment required. Joining our practice membership scheme, The Platinum Plan is mandatory for this limited guarantee.
- • Excessive forces such as grinding, clenching or chewing hard objects and sometimes normal wear and tear over time may result in fracture or debonding of restorations and component parts or loosening of screws retaining parts which may require further treatment at additional cost to you.
- • I advised as there is no nerve supply to implants to indicate overloading it is common to use screw retained work or cement the final work with a semi permanent or provisional cement so that components like screws and the implant head can be accessed and tightened and checked if required without damaging the final restorations to access them. Sometimes it is not possible to use screw retained restorations especially at the front of the mouth for aesthetic reasons so the screw hole is not visible and in those cases where implant placement is not ideal and governed by the remaining bone.
- The semi permanent or provisional cement used (such as tempbond or premier implant cement) is strong when biting down but pulling forces such as from sticky foods like toffees can de-bond the final restorations which can then require re-fixing at additional costs to you. These type of foods should be avoided to reduce this risk. If a permanent cement is used such as Fuji plus and internal components loosen the final restorations will require grinding to access the components and screw then the restoration and occasionally even the dental implant may require replacing at additional cost and time to you.
- The choice will be given to you but it is advisable to use a semi permanent cement where possible and only consider a more permanent cement if the work continually de-bonds for any reason or after the first year. You accepts the risks involved with this.
Maintenanceand monitoring of dental implants and teeth and mouth long term discussion
• I advised you that it is essential that the dental implants are monitored and maintained after the completion of treatment. The survival rate of good quality dental implants (the root part of the new tooth) placed by an experienced dental surgeon and regularly maintained and monitored has been reported to be approximately 95+% over 10 years. However like natural teeth, fillings and crowns they require regular monitoring and maintenance as the oral environment subjects the teeth and implants to many harsh chemicals, acids and heavy forces during function which could have an adverse effect on their health and cause premature fracture, debonding or failure.
Platinum Dental plan details:
Platinum Dental plan details:
- • After completion of treatment I recommended that you attend the surgery 6 monthly with the dentist to monitor the implants, your mouth and soft tissues and your teeth and also attend for hygiene care every 3 months to maintain a high standard of hygiene and gum health around the dental implant and restoration and natural teeth. All of this is included with the Platinum Dental Plan.
- • Terms and conditions and exclusions of any guarantee of the dental implant treatment apply which we discussed in detail and especially excludes people who have high risk factors described earlier, such as smokers, diabetics, parafunctional habits like grinding and clenching, very ill patients in poor health, and those patients who do not follow our recall attendance advice to see the dentist and hygienist, and normal wear and tear and changes in medical conditions. I also advised you to see our website and leaflet which has the full details and terms.
I agree and accept all the risks*
- Yes
- No
Informed consent to treatment: Dental Implant Treatment Consent
I understand that the treatment I am about to undertake, all options and risks have been explained to me and I have had the opportunity to ask any questions. I hereby give valid consent for this treatment.
REFUSE Informed consent to treatment: Root Canal Patient Consent
I choose to refuse the advised treatment, I agree to release Parrock Dental from any liability for any adverse effects of my decision (this may include the loss of bone and teeth). I refuse the above treatment and understand the possible consequences.
Consent
1. Take 2 painkillers at home 1 hour before your implant surgery appointment time. (Ibuprofen 400mg each x2 tablets or if you can't take this then take paracetemol 500mg x2). If you are taking painkillers already discuss this with your dentist but usually take these instead.
Consent
2. Begin taking Arnica tablets (from Boots or Holland & Barrett) and Vitamin C and Vitamin D supplements 2 week before, and continue taking 2 week after your appointment, for optimum healing.
Consent
3. Make sure you have a good breakfast or lunch before your appointment to avoid feeling faint and anxious and in case you may not be able to eat for a few hours.
Consent
4. Continue taking all normal medications.
Consent
5. If you are undergoing any sinus surgery ensure you do not have a cold or flu symptoms. In some cases we may need to reschedule your appointments. If this is the case please discuss this with your dentist as soon as possible.
Consent
6. If you are a smoker, please try to stop smoking at least 2 weeks before surgery and for 2 weeks after.
Consent
7. If you have diabetes please ensure your sugar levels are within the normal range and are well controlled.
Consent
8. Both smoking and diabetes are risk factors in poor healing after surgery.
Signature*
Date of Signature
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
Consent to treatment
All foreseeable risks of botulinum toxin therapy listed above have been thoroughly explained to me. My questions regarding the treatment procedure, its potential side effects and contraindications were answered to my full satisfaction. I also had adequate time to consider my decision. I understand that I am free to revoke my consent at any time without the need to give any reasons. By placing my signature below, I declare my consent to cosmetic treatment with botulinum toxin type A.
Signature*
Date of Signature
X-Ray and Ct scan consent
Consent - X-Ray and Ct scan consent
I being a person of sound mind, hereby give my permission for the dentist named above to take any xrays or ct scans necessary for my dental treatment. I understand that these xrays or ct scans may be free of charge due to any current special offers. In the future if I decide I would like to request copies of any x-rays or ct scans then the normal fee will be applicable for having them taken and copying on to a disc.
Signature*
Relationship to patient (if next of kin)
Date of Signature

Consent forms

Your Details

Periodontal treatment consent

As with all medical procedures, there are risks and potential complications associated which you must be aware of before you proceed with treatment:

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.

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:

Teeth Whitening Consent

Extraction Consent

Denture Consent

Root Canal Patient Consent Form

Informed consent to treatment

Dental Implant Pre-treatment Consent

The options were discussed in detail with you for replacing the missing teeth which included:

Platinum Dental plan details:

Botulinum Toxin Therapy for Wrinkle Correction

X-Ray and Ct scan consent