RENAISSANCE FAMILY AND COSMETIC DENTISTRY
2180 EAST BIDWELL STREET #100
FOLSOM, CA 95630
DENTAL SEALANTS INFORMATION & CONSENT FORM
Sealants help to prevent caries (decay) in the pits and grooves of posterior (back) teeth. They do not prevent decay on all surfaces of the tooth. Proper brushing and flossing is still necessary, or decay can develop.
Potential benefits of sealants:
Prevention of decay on the biting surfaces of back teeth.
Risks include but are not limited to the following:
- Replacement every few years, which is commonly needed but may not be covered by dental insurance
- Breakage of sealants, which is common with certain habits such as chewing ice or other hard foods
- Early loss of sealants, which can be caused by bruxism (tooth grinding)
Changes in treatment plan: during the course of treatment, procedures may need to be added, expanded, or changed if the dentist finds conditions that were not identified during examination and first observed during the course of treatment. The most common scenarios include the need for root canal therapy and more extensive restorative procedures like crowns, bridges, or implants. Permission is hereby given to perform any additional or expanded dental services that the dentist determines to be necessary. Further, at the dentist’s discretion, I may be referred to a specialist for further treatment, the cost of which may be my responsibility.
I understand that my child’s diet and oral hygiene will influence the longevity of dental sealants. Decay can form around sealants. Replacements may or may not be covered by my dental insurance. I have discussed treatment alternatives, risk, outcomes and cost with my dentist and have 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.