General Consent Form

Local Anesthesia
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.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of surroundings and able to respond rationally to questions and directions. I understand I am able to drive myself to and from my appointment.
This field is required.
Oral Sedation:
I understand that I will need to have a driver to and from my appointment while taking oral sedation.
This field is required.
Composite Filling:
Enter Tooth Number
Removal of decay and placement of composite filling material with bonding agent, in order to repair the tooth with the intent to regain full function.
This field is required.
Porcelain Crown:
Enter Tooth Number
Preparation of the tooth/teeth for permanent restoration, due to decay and cracks, or cosmetic purposes. I understand 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. I acknowledge that the above procedure could result in damage to the nerve and a root canal may be needed.
This field is required.
Permanent Restoration:
Enter Tooth Number
Once the tooth/teeth are cemented, they cannot be removed for changes, such as shade or shape. I understand that any changes made after permanent cementation will be my financial responsibility.
This field is required.
Scaling and Root Planing + Laser Therapy:
Enter Tooth Number
Non-surgical periodontal treatment will include the removal of calculus, bacterial plaque, and bacterial toxins. The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by my individual immune system.
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
Patient/Guardian Signature
Signature is mandatory.
Date
Witness Name
type witness name here

Local Anesthesia
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.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of surroundings and able to respond rationally to questions and directions. I understand I am able to drive myself to and from my appointment.
This field is required.
Oral Sedation:
I understand that I will need to have a driver to and from my appointment while taking oral sedation.
This field is required.
Composite Filling:
Enter Tooth Number
Removal of decay and placement of composite filling material with bonding agent, in order to repair the tooth with the intent to regain full function.
This field is required.
Porcelain Crown:
Enter Tooth Number
Preparation of the tooth/teeth for permanent restoration, due to decay and cracks, or cosmetic purposes. I understand 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. I acknowledge that the above procedure could result in damage to the nerve and a root canal may be needed.
This field is required.
Permanent Restoration:
Enter Tooth Number
Once the tooth/teeth are cemented, they cannot be removed for changes, such as shade or shape. I understand that any changes made after permanent cementation will be my financial responsibility.
This field is required.
Scaling and Root Planing + Laser Therapy:
Enter Tooth Number
Non-surgical periodontal treatment will include the removal of calculus, bacterial plaque, and bacterial toxins. The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by my individual immune system.
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
Patient/Guardian Signature
Signature is mandatory.
Date
Witness Name
type witness name here