We would like to take this opportunity to welcome and thank you for joining our dental practice. We appreciate your confidence in us and we will do everything possible to provide you with the finest dental care. Please take a few minutes to answer the following questions so we can assist you with your dental needs. The better we communicate, the better we can care for you.

Mailing Address, If Different:
I authorize the release of any information necessary to process my claims.

To avoid misunderstanding regarding insurance, we wish our patients to know that ALL PROFESSONAL SERVICES RENDERED ARE CHARGED DIRECTLY TO THE PATIENT and that PATIENTS ARE PERSONALLY RESPONSIBLE FOR PAYMENT OF FEES. We will prepare necessary forms or reports to help you to obtain your benefits from insurance companies. We do not render our services or the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient. There will be an additional fee for letter or reports.

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits to be payable directly to the undersigned dentist and I am financially responsible for non-covered services. I also authorize the doctor to release any information requested.

I authorize treatment of the above named person and agree to pay all fees charged for such treatment. I agree to pay all charge for members of my family and myself, shown by statements, promptly upon presentment thereof, unless credit arrangements are agreed upon in writing.

Have you ever had any of the following diseases or medical problems?
Any other serious medical conditions:
Are you allergic to any of the following?
General Dentist:

I have completed this form to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

So that we may assure you and other patients of uninterrupted treatment it is necessary for all patients to accept a definite arrangement for the appointments. Once an appointment is made, please remember this time is reserved for you.

Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.


Please list all medications, including over-the-counter (OTC) medications. If you aren't taking any medications, please put "N/A" on the first line.

The Prosthodontic Dental Group
Facts You Need To Know

"Quality is never an accident, it is always the result of high intention, sincere effort, intelligent direction, and skillful execution; it represents the wise choice of many alternatives."

ESTHETIC CONSIDERATIONS: It is our intent to use our technical and artistic capabilities to achieve your esthetic expectations and to incorporate these factors into your final dental restorations. You are asked to communicate your desires, and our best efforts will be applied toward incorporating your wishes in harmony with the functional and physiological requirements of the restorations. After your approval, the restorations will be finalized. Please note that only very MINOR changes to the shape of the restorations can be made after finalization. NO changes to color can be made after finalization. Some changes in appearance may be beyond the capabilities of restorative and prosthetic dentistry. A consultation with other dental or medical specialists may be suggested.

POTENTIAL PROBLEMS WITH FIXED PROSTHODONTICS: Crowns and fixed bridges are used to treat problems of decay, severely worn or fractured teeth, malocclusion, and to protect teeth that have had root canal treatment. However, because dental restorations are replacements for natural teeth, potential problems do exist. The following pages briefly describe the most commonly encountered problems. Questions about your specific case are encouraged.

IMPLANTS: Longevity depends on many factors — the patients health, the use of tobacco, alcohol, drugs, sugar, oral hygiene, the amount of quality bone, surgical compromises, the degree of biting force, etc. As with any restorative procedure, the potential exists for the fracture of an implant component, implant crown, or loss of the implant from the bone, or infection.

PROVISIONAL (Temporary) RESTORATIONS: Provisional crowns and fixed bridges are used to protect the teeth and to provide a satisfactory appearance while the new permanent crown(s) and fixed bridge(s) are being fabricated. A provisional restoration is usually made of acrylic resin, which is not as strong as the final porcelain/metal restoration. A provisional is attached to the teeth with temporary cement, therefore, it is important to minimize the chewing pressure on a provisional restoration since it can fracture and/or become dislodged. If this does occur, call our office as soon as possible for repair or recementation. Waiting more than a few days can create unnecessary problems, and may delay your treatment. Delay in finalization of your treatment can cause dental problems including decay, gum disease and need for repeat treatment.

PORCELAIN FRACTURES: Porcelain is the most suitable material for the esthetic replacement of tooth enamel. Because porcelain is a "glass-like" substance, it can break. However, the strength of dental porcelain is similar to dental enamel, and the force necessary to fracture dental porcelain would usually fracture natural tooth enamel. Small porcelain fractures can be repaired; larger fractures often require a new crown or fixed bridge.

STAINS and COLOR CHANGES: All dental restorative materials can stain. The amount of stain generally depends on oral hygiene as well as the consumption of coffee, tea, tobacco, and some types of foods or medicines. Dental porcelain usually stains less than natural tooth enamel, and the stain can be removed at dental hygiene cleaning appointments. Natural teeth tend to darken with time more so than porcelain crowns. At the time a new dental porcelain crown or fixed bridge is placed, it may be an excellent color match with the natural teeth. Over time, however, this may change and bleaching or other appropriate treatment may be suggested.

BLEACHING: Bleaching provides a conservative method of lightening teeth. There is no way to predict to what extent a tooth will lighten. In a few instances, teeth may be resistant to the bleaching process, and other treatment alternatives may be advised. Infrequently, side effects such as tooth hypersensitivity and gum tissue irritation may be experienced. If these symptoms occur, technique modifications or products can usually alleviate the problem(s).

TOOTH DECAY: Some individuals are more prone to tooth decay than others. With a highly refined carbohydrate diet or inadequate home care, tooth decay may occur on areas of the tooth or root not covered by a dental crown. If the decay is discovered at an early stage, it can often be filled without remaking the crown or fixed bridge. Long delays in treatment, a loose provisional or permanent crowns and bridges can result additional decay, the "death" of a tooth nerve, which would require a root canal or even the loss of a tooth and/or teeth.

LOOSE CROWN or LOOSE FIXED BRIDGE: A dental crown or fixed bridge may separate from the tooth if the cement is lost or if the tooth fractures beneath it. Most loose crowns and fixed bridges can be recemented, but teeth that have extensive recurrent decay or fractures will usually require a new crown or new fixed bridge.

EXCESSIVE WEAR: Sometimes crowns and fixed bridges are used to restore badly worn teeth. If the natural teeth were worn from clenching and grinding the teeth (bruxism), the new crowns and fixed bridges may be subjected to the same wear. In general, dental porcelain and metal alloys wear at a slower rate than tooth enamel. However, excessive wear of the crowns or fixed bridges may necessitate an acrylic resin mouth guard (also called a protective occlusal splint or night guard.)

DENTURES: Partial and complete dentures are removable replacements for natural teeth. They are not the same as teeth. At delivery, most people feel a sense of fullness/foreignness with new dentures that decreases with time. Speech is usually temporarily affected and takes adaptation. Most people find that with dentures they are not able to eat all the foods they could with their natural teeth. Gum soreness usually occurs with new dentures and is controlled with post delivery adjustments. Soreness can occur later if biting pressure exceeds tissue tolerance. Dentures move during use. The overall tightness and stability of appliances varies from patient to patient depending on their anatomy and the skill they develop to control the appliances. Overall satisfaction with comfort, function, and esthetics cannot be predicted in advance.

ADDITIONAL INFORMATION: Sometimes when teeth are prepared for crowns, due to the extent of wear, deep decay, large fillings or old crowns, the additional "trauma" to an already compromised tooth can possibly cause the nerve of the tooth to die. This usually requires a referral to an endodontist, a specialist who does root canal treatment. It does not normally require changes in your treatment plan. Also whenever teeth are treated with fillings, crowns or veneers there is a risk of complications which include pain, numbness, nerve injury, sensitivity, gum recession, cuts, or injuries the soft tissues, fracture of teeth, allergic reactions to materials used in the treatment process and final restoration.

MAINTENANCE: Even the most beautiful restorations can be compromised by gum problems, recurring cavities, and poor oral hygiene habits. Part of our commitment to you is to provide you with the proper information to keep your gums and teeth (natural or restored) in good health. Professional cleaning by a dental hygienist at recommended intervals keeps your mouth healthy and can intercept potential problems early enough to avoid additional restorative work or unnecessary discomfort.


I certify that I have read and understand all of this INFORMED CONSENT which outlines the general treatment considerations as well as the potential problems and complications of restorative/prosthodontic treatment. I understand that potential complications and problems may include, but are not limited, to those described in this document. I have been given the opportunity to ask questions about the proposed treatment and the risks, as well as the potential consequences should elect to postpone or refuse treatment, I understand that during and following treatment. conditions may arise that warrant additional or alternative treatment. I further understand that no guarantees can be made fora successful result.

Recognizing the potential problems and risks of restorative/prosthodontic treatment, authorization is given for dental treatment to be rendered by the dentist and office staff. I also approve, after full discussion of all aspects of my treatment, any modification in design. materials or care if it is believed to be in my best interest. In addition, I grant permission for photographs of the procedures to be shown for teaching purposes only. provided my identity is not revealed.

Patient Acknowledgement of Receipt of Dental Materials Fact Sheet

Purpose: This form is used to obtain acknowledgement of receipt of our Dental Materials Fact Sheet.

"I acknowledge that I have reviewed this office's Dental Materials Fact Sheet from the link(s) below and that it is recommended I download and/or print a copy for myself."

View Dental Materials Facts Sheet

Ver Hoja de Datos de Materiales Dentales

Patient Acknowledgement of Receipt of Notice of Privacy Practices

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement

"I acknowledge that I have reviewed this office's Notice of Privacy Practices from the link below and that it is recommended I download and/or print a copy for myself."

View Notice of Privacy Practices

Consent for the Use and Disclosure of Health Information

Purpose: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of privacy practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any or your protected health information that we maintain. You may obtain a copy of our Notice of privacy practices, including any revisions of our Notice, at any time by contacting your doctor.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation, submitted to your doctor. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent

"I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations."