Cosmetic Prep Consent | Patient Form
Cosmetic Prep Consent
Porcelain Restorations Consent (Porcelain Veneers/ Crowns)
Name
First Name
Last Name
Tooth/Teeth Number(s)
I understand that with porcelain restorations, the color, shape, and alignment of my teeth will be improved. The porcelain restorations will only be used to improve the appearance of my teeth. If my bite is off, or my teeth don’t come together properly, if there is a discrepancy of my facial midline, if there is severe crowding/misalignment, severe spacing, and/ or dental crossbite, in order to achieve optimal results, traditional orthodontics is an option. If any of the above is present, I also understand that traditional orthodontics will take up to 2 years to correct and that porcelain restorations would still be recommended after completion of orthodontics to improve the shape and color of the teeth. With the use of porcelain restorations Dr. Sluyk will attempt to improve the conditions above. I understand that some of these conditions may not be fully improved due to the limitations of porcelain restorations and the current condition and position of the teeth.
This field is required.
I understand, in order to receive porcelain restorations, the teeth must be reshaped to allow sufficient thickness of the porcelain material and also to achieve a straighter alignment of the teeth and to mask any discolorations. Dr. Sluyk will be as conservative as possible in order to maintain the health of the teeth, but also will take into consideration the end ideal result.
This field is required.
While having the teeth reshaped and restored, I am aware that in the process if the teeth become irritated and/or if I have prior dental work that is being replaced, the nerve of the teeth may need to be treated by undergoing root canal therapy. Oftentimes, there is decay underneath older restorations that will be removed. If the decay extends to the nerve canal or if the tooth becomes inflamed from having been worked on, root canal therapy may be required. If the teeth are severely misaligned more tooth structure will have to be removed to achieve a more ideal result. This process may expose or bruise the nerve, resulting in root canal therapy. Again, Dr. Sluyk will be as conservative as possible in order to maintain the health of the teeth but will also consider the end ideal result. Root canal therapy may need to be done during the temporary phase or even months to years after treatment has been completed. If I undergo root canal therapy after treatment has been completed, I may have to have restorations replaced due to weakening or fracturing of the restoration after root canal therapy.
This field is required.
During the cementation appt, if there are minor alterations desired to the contours, they can be done in the office, but if I wish to change the color or major shape of the teeth, the restorations may have to be sent back to the lab and tried in and cemented at another time, in order to make the desired changes. If the restorations have been approved prior to permanent cementation and the patient, then wishes to change the appearance of the restorations or color after they have been permanently cemented that require the restoration to be redone- then the restoration will be redone at a designated porcelain/lab/material fee. Dr. Sluyk may also recommend that I wear a custom designed bite guard at night after I have completed treatment to help protect the permanent restorations.
This field is required.
Payment is due at the smile design appointment, on that appointment all records, information, impressions are taken, and the case is sent to the lab to design. We will also schedule all the appointments as well. To receive a cash discount the cost of the treatment must be paid in full via cash or check. All financing must be completed at the smile design appointment and prior to scheduling any appointments for treatment. *Refund policy: if at any time during treatment you choose to not go forward with the treatment for any reason and your case has already been sent to the lab, we will refund the full amount minus a lab fee of $300 per tooth. Once the case is completed, no refund will be issued.
This field is required.
After treatment is completed, if my bite is not aligned or is off, or if I grind/clench my teeth I may experience TMJ symptoms, jaw soreness, sore teeth, temperature sensitivity or even fractures of the restorations. If this occurs Dr. Sluyk will address the issue and further adjust the bite or remake the restorations if needed. If restorations are fracturing, multiple restorations may need to be redone. *If the restorations need to be redone due to fractures or chipping or breakage, then the restoration will be remade at no charge to the patient if it is during the Warranty Period of 3 yrs. Years 4-5, the Patient will be responsible for the lab fee to remake. After 5 years, there is no warranty — this policy only applies at Dr. Daniel Sluyk’s office. It also only applies if the patient keeps up with regular cleanings and check-ups at recommended intervals. Each patient is asked to complete his/her minimal twice per year checkups and cleanings in order to help maintain the restorations and so that Dr. Sluyk can ensure that there are no concerns arising with the health, appearance and/or function of the teeth.
This field is required.
Local Anesthesia Consent:
By receiving local anesthetic, there is a possibility of temporary or permanent numbness of the lip, tongue, chin, cheek, as well as, thrombophlebitis (inflammation of the vein), temporary TMJ problems, and possible allergic reaction.
This field is required.
Social Media Release:
I agree to have photographs and videos taken while being at Dr. Daniel Sluyk Family and Cosmetic Dentistry and understand that these may be posted to social media.
This field is required.
Patient Name
First Name
Last Name
Date question
Patient/Guardian Signature
Clear
Signature is mandatory.
Witness Name
First Name
Last Name
Witness Signature
Clear
Signature is mandatory.
Submit