FOLSOM, CA 95630


I UNDERSTAND that treatment of my dentition for which I desire cosmetic dental procedures to be performed may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and / or failure associated with, but not limited to the following: (even though care and diligence is exercised in this subject treatment, there are no guarantees of anticipated or desired results or of the longevity of the treatment).

1. Reduction or roughening of tooth structure : In making preparation of teeth for the reception of cosmetic veneer(s) may be bonded. This preparation will be done as conservatively as possible. If the veneer covering breaks or comes off, the uncovered tooth may become more decay susceptible.

2. Sensitivity of teeth : Even though, in the majority of the cases (whitening, bleaching bonding, and veneering teeth) there is usually no appreciable sensitivity; this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination.

3. Chipping, breaking or loosening of the veneer : No matter how well done, this could occur. Many factors may contribute to this happening such as; mastication of excessively hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; breakdown of the bonding agents; inconsistent or no use of night guard and other such conditions over which the doctor has no control.

4. Sensitive or allergic reactions of soft tissues to whitening, bleaching or bonding agents : Even though this is an unusual occurrence, the gums or soft tissues of the mouth which may be exposed to the various agents used in these procedures may exhibit an allergic response. Also, gum tissues may in some cases exhibit signs of inflammation. Should this occur please contact this office to be examined.

5. Esthetics/Appearance : Every effort possible will be made to match and coordinate both form and shade of veneers and/ or bonding agents which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences which may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/ or form perfectly match your natural dentition.

6. Longevity : It is impossible to place any specific time criteria on the length of time that veneers and bonding should last or for the lightened appearance of whitened or bleached teeth to maintain the lightened shades. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/ or upon each patient’s individual habits or circumstances, which may be either internal, external or both.

7. It is the patient’s responsibility to immediately inform the doctor and seek attention from him/ her should any undue or unexpected problems occur or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling and attending all appointments.

INFORMED CONSENT: I can read and write English and have been the opportunity to ask any questions regarding the nature and purpose of the proposed treatment 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. 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 the doctors and staff at Renaissance Family and Cosmetic Dentistry involved in rendering any services they deem necessary or advisable to treatment of my dental conditions, including the administration and/or prescribing of any anesthetic agents and/ or medications.

Anesthetic : The use of local anesthetic is used for pain control during dental procedures. There are inherent risks and side effects. They include, but not limited to: swelling, bruising, soreness, elevated blood pressure or pulse, allergic reaction, and altered sensation that may lead to self-injury. Partial or complete numbness may linger after the dental appointment. In rare cases it can last for an extended time and potentially it can be permanent.

Medications : Any medications dispensed or prescribed are the patient’s responsibilities to clarify with the pharmacist before taking. Articular attention should be given to possible allergic reactions; drug interactions with current medications and their specific side effects.

Notifications : If a patient develops a problem it is the patient responsibilities to notify the doctors and/ or staff of Renaissance Family and Cosmetic Dentistry. Through this notification we will be able to act on the patient’s behalf. Attempts to correct a problem may occur at our office or a referral to another health care practitioner may be warranted.

Treatment Cancellation and Interrupted Service Charges 

Once impressions are sent to the lab, patients are liable for the estimated full cost of the services even if they choose not to complete treatment.

I have discussed treatment alternatives, risk, outcomes and cost with my dentist and have has had all of my questions answered before making a decision. I understand that dentistry is not an exact science and that there are no guaranteed results. A predetermination of benefits is not a guarantee of coverage. In all cases I am responsible for amounts not covered by my insurance, unless prohibited by law or contractual agreement. I can read and write English and have been given the opportunity to ask questions regarding the nature and purpose of the proposed treatment and have received answers to my satisfaction.

Having had adequate time to reflect upon the alternatives, I consent to the treatment, subject to changes in treatment plan, and accept complete financial responsibility as detailed above.

Disclaimer: Due to the cosmetic nature of these procedures, dental insurance benefits are not available.