CROWN LENGTHENING CONSENT FORM

  1. I understand that I have been diagnosed with the following problem(s):
    1. Deep filling or fracture of the tooth close to the bone which does not allow for proper restoration or placement of a crown.
    2. The clinical crown is too short to place an adequate retentive crown.
  2. I understand that the following treatments are recommended:
    1. Crown lengthening procedure on tooth/teet that involves reflection of soft tissue flaps for access accompanied by soft and hard tissue (bone) recontouring under local anesthetic.
    2. This procedure can also be conducted under oral sedation or intravenous conscious sedation.
    3. This treatment may include the use of local anesthetic, antibiotics, analgesics, sutures (stitches) and a wound dressing if required.
  3. I was also informed of the following alternate treatments:
    1. No crown lengthening, difficult to do a crown
    2. No crown lengthening, no crown
    3. Extraction with bone graft
  4. The anticipated length of treatment, although I realize that it may vary greatly between patients and may be influenced by my own level of cooperation and participation and the availability of clinical appointments, and may be delayed by unforeseeable clinical and technical setbacks, has been explained as follows:
    1. Surgery time:
    2. Post-op: 7, 14, 21 days after surgery 15 min apt
    3. Final crown: Minimum 6-8 weeks after surgery, 6 months for esthetic area
  5. I understand that risks related to the recommended treatments may include, but are not limited to the following:
    1. Allergic reactions to any dental products, materials, and medications
    2. Bleeding
    3. Swelling, ecchymosis 2
    4. Infection e. Pain
    5. Exposure of the root surface (recession) and/or dentinal hypersensitivity
    6. Exposure of gaps between the teeth
    7. Exposure of crown and bridge joints
    8. Temporary restriction of mouth opening
    9. Increase tooth mobility
    10. Possible paresthesia of dental nerves (teeth, lips, tongue, cheeks, palate…)
  6. I understand that refusing treatment of my condition may impact on my oral and general health. Consequences may include but are not limited to:
    1. Impossibility to do the crown
    2. Progression of loss of bone support around tooth/teeth
    3. Premature loss of tooth/teeth
  7. I understand the necessity of maintaining good oral hygiene for better healing and the importance of post-surgical appointments. I also understand the importance of strictly following my periodontist’s recommendations. Tobacco and alcohol products may affect healing negatively after periodontal surgeries and may also affect maintenance of surgical results.
  8. I understand that I have been given no warranty nor guarantee pertaining to the success of the suggested treatment. In most cases the suggested treatment should reduce the causes of my periodontal condition and may permit me to keep my teeth for a longer period. Because of variations with patients’ home self-oral care and medical health, the periodontist cannot positively predict the success of provided treatments. Even with optimal treatments, there are always risks of failure which may require re-treatment. The risks of degeneration of my periodontal condition may be still present and may lead to loss of teeth.
  9. I authorize the use of photography, radiography and/or any other documentation, which pertains to care and treatment that I received, to be used for promoting advancement in dentistry. However, my identity will never be shown or discussed to the public without my written consent.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

  • Pre and post treatment instructions have been explained to me.
  • I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
  • I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
  • Must notify the clinician if my medical history changes prior to subsequent treatments.
  • I consent to clinical photographs being taken of my treated areas for my personal health record only.
  • There are no refunds for services rendered and/or after a year from purchase and not used.
  • The treatments I receive here are voluntary and I release KAI LIFE Clinic, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
  • My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.



Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date