Informed Consent for Dental Treatment
Dr. Roger D. Sohn, D.D.S., 24950 Redlands Blvd. Suite B, Loma Linda, CA 92354


I understand that I am having the following dental treatment:

Impacted teeth removed
Root canal therapy
Perio/Gum a treatment

1. DRUGS, MEDICATIONS AND ANESTHETICS. I understand that antibiotics, analgesics and other medications can cause allergic reactions such as redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock.

2. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy may be necessary following a routine restorative procedure. I give my permission to the Dentist to make any necessary changes or additions. I understand that the Dentist will make 5 every effort to inform me should this situation arise.

3. PERIODONTAL LOSS (TISSUE & BONE): I understand that I have a condition causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. Altemative treatment plans have been explained to me including scaling, root planing, gum surgery, replacements and/or extractions. I understand that undertaking periodontal therapy may provide for the survival of my natural dentition. Refiisal of therapy and control may have an adverse effect on my future periodontal condition.
4. FILLINGS: I understand that care must be exercised in chewing on new fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is common after receiving a newly placed filling. It is not unusual to have root canal infection if the decay was deep. In which case, I understand a Root Canal Treatment and a crown work has to be performed on my own expense.

5. CROWNS, BRIDGES AND CAPS: I understand that sometimes it is not possible to match the exact color of natural teeth with artificial teeth. I funher understand that I may be wean'ng temporai'y crowns, which may come off easily and that I must be canefiil to ensure that they are kept on until the pennanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size, and color) will be before cementation. It is also my responsibility to return for permanent cementation within 30 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown, bridge, or cap. I understand there will be additional fees. It is not unusual to have root canal infection if the decay was deep. In which case, I understand a Root Canal Treatment has to be performed on my own expense.

7. ENDODONTIC TREATMENT (ROOT CANAL): I understand that root canal treatment is an attempt to save a tooth due to loss of vitality from infection, decay, or in restorative procedures to obtain suflicient retention for restoration. The procedure has been explained to me and I have been informed that occasionally there are 5 complications concerning this treatment. These complications could include: allergic reactions to medications or anesthetics used, pain, swelling, or sensitivity to pressure during or after canal is sealed. Treatment may have to be discontinued due to calcified canals, inaccessible canals, perforation, resorption, accidental broken files or reamers, fracture of root or crown. Surgery may be indicated to remove the cystic or infected apical portion of the root and bone to complete treatment. The crown of the tooth may darken eventually and/or become brittle, due to root canal treatment. The dentist may recommend crowns be placed on some root canal teeth.

8. REMOVAL OF TEETH (Extractions): Alternatives to removal have been explained to me (root canal therapy, crowns and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and further treatment may be necessary. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infections, dry socket, loss of feeling in my teeth, lips, tongue and sumounding tissue (Parasthesia) that can last for an indefinite
period of time, or fractured jaw. I understand that I may need further treatment by a specialist if complications arise during or following treatment, the cost of which is my responsibility.

9. DENTURES: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of dentures immediately afier extractions) may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed laterl This is not included in the original denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. I f a remake is required Initial due to my delays of more than 30 days there will be additional charge.

I understand that dentistxy is not an exact science and therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized. I understand that each Dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist is responsible for my
dental treatment.

I hereby authorize any of the doctors or dental auxilian‘es of Dr. Sohn, to proceed with and perfonn the dental restorations and treatments explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of dental fees. I agree to pay any attorney's fees, collection fees, or court costs that may he incurred to satisfy this obligation.

Should any dispute arise over dental services provided to me, whether any dental service rendered was allegedly unnecessary, unauthorized or was improperly, negligently, or incompetently performed, said dispute will be submitted to Peer Review by the local component of The American Dental

Witness Signature
Name of Witness
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