I ACKNOWLEDGE that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGE WORK includes certain risks and possible unsuccessful results, including the possibility of failure. Even though care and diligence are exercised in the treatment of conditions requiring crowns and bridgework and fabrication of same, there are no promises or guarantees of anticipated results or the longevity of the treatment.

Nevertheless, I agree to assume the risks, possible unsuccessful results and/or failure associated with, but not limited to the following:

Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as possible.

Injury: During the reduction of tooth structure or adjustments done to temporary restorations, it is possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut). In some cases, sutures or additional treatment may be required.

Local Anesthesia: In order to reduce tooth structure without causing undue pain during the procedure, it will be necessary to administer local anesthetic. Such administration may cause reactions or side effects which include, but are not limited to, bruising, hematoma, cardiac stimulation, temporary or, rarely permanent numbness of the tongue, lips, teeth, jaws and/or facial tissues, and muscle soreness.

Sensitivity of teeth: Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity, which can range from mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If sensitivity is persistent, this office should be notified immediately such that all possible causes of the sensitivity may be ascertained.

Crowned or bridge abutment teeth may require root canal treatment subsequently: Teeth after being crowned may develop a condition known as pulpitis or pulpal degeneration. Usually, this cannot be predetermined. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth, particularly if teeth remain appreciably sensitive for a long period of time following crowning. Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical surgery or even extraction may be necessary.

Breakage: Crowns and bridges may possibly chip or break. Many factors can contribute to this situation such as chewing excessively hard materials, changes in biting forces exerted, traumatic blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes.

Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminable periods of time following placement of the crown or bridgework.

Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation.

Longevity of crowns and bridges: There are many variables that determine "how long" crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Because of this, no guarantees can be made or assumed to be made concerning how long crown and bridgework will last. Because crowns and bridges are statistically more reliable over a longer period of time than fillings, in the case of access restricted patients, consideration will be given to choosing a crown or bridge more often than a repair or filling involving the interproximal areas.

It is the patient's responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow all instructions, including the scheduling and attending all appointments.

Informed Consent:

1. I understand that it is my responsibility to notify Dr. Ahmed or Associates, should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.
2. I authorize Dr. Ahmed, and Associates to perform upon the above named patient any and all procedures, including but not limited to local anesthetic, cleaning, x-rays, and any and all procedures that in their judgment may be necessary or advisable for the above patient's wellbeing and safety.
3. I acknowledge that I have been thoroughly explained, their alternatives with their pros and cons and/or risks and complications involved. I have been provided with various treatment options, such as but not limited to: Partial dentures (Cast/ acrylic), Implants/implant supported bridge, Complete dentures, Maryland bridge, No treatment.
4. It has been explained to me, that during such procedure(s) or operations(s), unforeseen conditions may be revealed which necessitate either an extension of the procedure(s), or modification of them. I authorize and do request that Dr. Ahmed and Associates perform any such additional procedure(s), or modifications of them.
5. I have been given the opportunity to ask any questions regarding the nature and purpose of crowns, bridges and fillings and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired and/or any results from the treatment to be rendered to me.
6. The fee(s) for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize Dr. Ahmed and Associates involved in rendering services he/she deems necessary or advisable to treatment of my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.
7. I understand that Dentistry is not an exact science and, therefore, a reputable doctor cannot guarantee any specific results. No Guarantee or assurance has been given by Dr. Ahmed or Associates of the expectations of results that may be achieved.

I have reviewed the above information and agree to all terms.