Mobile Dental Forms

Complete necessary patient paperwork quickly for home visits.

HIPAA

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

  • when a state or federal law mandates that certain health information be reported fora specific purpose;
  • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
  • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
  • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
  • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to bea victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
  • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
  • uses or disclosures for health related research;
  • uses and disclosures to prevent a serious threat to health or safety;
  • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking govemment officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • disclosures of de-identified information:
  • disclosures relating to worker's compensation programs;
  • disclosures of a "limited data set" for research, public health, or health care operations;
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
  • disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information;
  • [EDIT: (specify other uses and disclosures affected by state law].]

Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may aiso call or write to notify you ofother treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:

  • ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice.
  • ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We willaccommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
  • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
  • ask us to amend your health information if you think that it is incorrect or incomplete. Ifwe agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. Ifwe do not agree, you can writea statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, senda written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
  • get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list willnot include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We willusually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. if you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
  • get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail show

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.

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In-Home Dental Care Pre-Visit & Intake Form

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In-Home Dental Care Pre-Visit & Intake Form

This form is designed to ensure safe, efficient, and well-prepared in-home dental care. Please complete this form prior to your scheduled visit. All information is confidential.

1. Patient & Location Information

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Address

2. Medical & Dental History

3. Dental Care Needs & Expectations

4. Environmental & Safety Screening

5. Administrative & Consent

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Medical History Form

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Mobile Dental Services Consent, Safety Expectations & Financial Terms

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Patient Consent

I authorize Dr. Jamel McDuffie and team members to provide mobile dental evaluation and treatment in my residence. I understand some procedures or emergencies may require referral to a traditional dental office or hospital.

Home Safety Requirements

I agree to provide a safe, well-lit workspace, secure pets, disclose occupants, and ensure pathways are hazard-free. Respectful conduct is required at all times.

Right To Terminate Services

Provider may terminate visits immediately if safety risks arise. Charges may stillapply if visits are ended due to unsafe conditions, misrepresentation, or failure to comply with safety expectations.

Mobile Care Limitations

I acknowledge that home-based care may have limitations compared to an equipped dental office and further treatment may be required elsewhere.

Privacy/HIPAA

HIPAA protections apply; however, maintaining privacy within the home environment is the patient's responsibility.

Financial Terms

Travel, mobilization, and appointment fees may still apply if visits are cancelled late or terminated due to unsafe conditions.

Caregiver Responsibility Clause

For patients requiring assistance due to mobility, cognitive impairment, medical complexity, or fall risk, a responsible caregiver must be present throughout the visit. McDuffie In-Home Dental Care is not responsible for supervision before or after treatment, and caregivers remain responsible for patient safety within the home environment.

Payment Authorization & Chargeback Protection

By scheduling services, the patient or responsible party authorizes charges related to scheduled mobile services, including travel and mobilization fees when applicable. Safety-related termination or late cancellations do not void applicable charges. Patients agree to contact the practice directly to resolve billing concerns prior to initiating credit card disputes or chargebacks.

Signatures

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Dental Treatment Consent Form

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Please read and initial the items checked below.

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I understand that I am having the following treatment and have been informed of the consequences of both having and not having the treatment done:
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, the most common being root canal therapy following routine restorative procedures. I give permission to the dentist to make any/all changes and additions as necessary and understand there may be additional costs involved.
I understand that I may be given antibiotics, analgesics and other medications and these can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction), etc.
I am aware that I consume certain medications which may cause a variety of health problems while getting such dental treatment done, I made the dentist aware of all the medications I am taking and I understand the risks. I am willingly allowing the dentist to provide my dental treatment and I am, myself, liable for any major health occurrences.
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Oral Surgery and Dental Extractions

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Informed Consent
Oral Surgery and Dental Extractions

For removal and/or surgery involving tooth (teeth)

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I UNDERSTAND that ORAL SURGERY and/or DENTAL EXTRACTIONS include possible inherent risks such as, but not limited to the following:

  1. Injury to the nerves: of the lips, the tongue, the tissues in the floor of the mouth, and/or the cheeks, etc. These possible nerve injuries can cause numbness, tingling, burning, and loss of taste in the case of the tongue which may be of a temporary nature lasting a few days, a few weeks, a few months, or could possibly be permanent
  2. Bleeding and/or bruising: Bleeding could last for several hours. Should it persist, particularly being severe in nature, it should receive attention and this office must be contacted. Bruising may possibly be prolonged due to the stretching and pulling of the cheek muscles and lips.
  3. Dry socket: occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry sockets can be extremely painful. Smoking, drinking liquids through a straw and not following post-operative recommendations can increase the chances of this complication.
  4. Sinus involvement: In some cases, the root tips of upper teeth lie in close apposition to the tissues of the sinuses. During extraction or surgical procedures, the thin bone and tissues surrounding the sinus membrane may be perforated. Should this occur, it may be necessary to have the sinus surgically repaired
  5. Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile or infected oral environment, for infections to occur postoperatively. At times these may become serious. Should severe swelling occur, particularly accompanied with fever or malaise, attention as soon as possible should be received and this office must be contacted. In some cases hospitalization and/or treatment with LV. antibiotics may become necessary.
  6. Fractured jaw, roots or bone fragments: There is a possibility, even though extreme care is exercised, that the jawbone, teeth roots or bone spicules may be fractured which may require referral to a specialist for treatment. A decision may be made to leave a small piece of root or bone fragment in the jaw when its removal would require extensive surgery and/or risk of complications. Small sharp bone fragments may work up through the gums during healing. These may require another surgery to smooth or remove them.
  7. Injury to adjacent teeth, fillings or porcelain crowns may occur no matter how carefully surgical and/or extraction procedures are performed. Fractured teeth, fillings or crowns may require replacement or additional restorations. Sensitivity may also occur to the remaining teeth.
  8. Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, the tissues of the heart in some cases and due to a number of conditions may be susceptible to bacterial infection transmitted from the mouth to the heart through the circulatory system. A condition called bacterial endocarditis (an infection of the heart) may occur which can result in damage to heart valves. If any heart problems are known or suspected (such as a heart murmur following rheumatic fever, existence of an artificial heart valve, cardiac damage following PhenFen use, etc.), the dentist must be informed prior to surgery.
  9. Muscle or jaw soreness: may be noticed following oral surgery and especially third molar extractions. Pre-existing conditions affecting the jaw joints (TMJ) may be aggravated by oral surgery. Clicking, popping, muscle soreness and difficulty opening may be noticed for some time following surgery. If such symptoms or conditions persist, the patient should call our office. The patient must notify the dentist of any such pre-existing conditions prior to surgery.
  10. Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. It is important to take all prescription drugs according to instructions. Women on oral contraceptives must be aware that antibiotics can render these contraceptives ineffective. Caution must be exercised to utilize other methods of contraception during the treatment period.
  11. Bisphosphonate Drug Risks: For patients who have taken drugs such as Fosarnax, Actonel, Boniva or any other drug prescribed to decrease the resorption of bone as in osteoporosis, or for treatment of metastatic bone cancer, there is an increased risk of osteonecrosis or failure of bone to heal properly following any oral surgical procedure involving bone, including extractions.
  12. It is my responsibility to contact the dentist and seek attention should any undue circumstances occur postoperatively and I shall diligently follow any preoperative and postoperative instructions given me.
  13. I UNDERSTAND THAT THE DENTIST AT MCDUFFIE DENTISTRY IS A CERTIFIED GENERAL DENTIST LICENSED TO PERFORM ORAL SURGERY AND THIRD MOLAR REMOVAL. I ALSO UNDERSTAND THATSHE/HE IS NOT AN ORAL ANDMAXILOFACIAL SURGEON. I CHOOSE NOT TO BE REFERRED TO AN ORAL AND MAXILOFACIAL SURGEON FOR THIS PROCEDURE.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and/or extraction of teeth and have received answers to my satisfaction. I have been given the option of seeking care with an oral and maxillofacial surgeon. Any possible alternative methods of treatment (if any exists such as root canal treatment, periodontics'/gum surgery, crowns, filling, etc.) were explained to me. 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 results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me. The fee {s) for this service have been explained to me arid are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. McDuffie and/or her associates to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications. I fully understand the extraction of a tooth (teeth) is an irreversible process and other teeth within the dentition may shift and/or change the bite. I also understand the replacement of missing tooth (teeth) by prosthetic procedures are recommended.

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Instructions After A Tooth Extraction

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Instructions After A Tooth Extraction

When a tooth is removed, a hole is left in the bone. A blood clot fills the hole to cover-up the bone. The blood clot is helpful to speed healing. If the blood clot is lost, bare bone becomes exposed. Dry exposed bone is called a "dry socket". Dry sockets are very painful and take a long time to heal. The blood clot must be protected to prevent a dry socket, therefore our office recommends the following to protect the blood clot.

TO PROТЕСТ ТHE BLOOD CLOТ

DO

  • Rest - For the remainder of the day
  • Ice -30 minutes on/30 minutes off for 2 hours to decrease swelling
  • Elevate - Your head for the remainder of the day
  • Gauze - Keep in place for at least I hour
  • Medications - If needed or given, take as directed on bottle
  • Nourishment - Soft foods and liquids today

DO NOТ

  • Smoke - Not for 48 hours
  • Rinse - Not for 24 hours; after 24 hours you may rinse with warm salt water
  • Spit - Not for 48 hours
  • Drink - Not with a straw
  • Alcohol - no alcoholic beverages for 24 hours
  • Sodas - No carbonated beverages for 48 hours

*If anything unusual happens or if you have a problem, please call the office.

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Partial/Complete Denture Processing Consent

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Partial/Complete Denture Processing Consent

I,

understand that a partial/complete denture will be made in the ideal teeth shape and size, to match my current arch, dentition or facial structure. I have had a chance to either confirm with the office in detail, my appearance and fit desires or to try the denture in wax and approve the appearance and fit.

I understand that when the new prosthesis (partial/complete denture) is processed and completed, that if I would like any aesthetic changes there will be additional costs involved of at least $600 (six hundred dollars) per prosthesis.

Immediate dentures are placed after the removal of teeth. During the healing process, the gum and bone in the area may shrink and change. Therefore, I have been informed and understand that I may need a reline of the partial/complete denture for better fit due to the changes of bone and gum tissue. The reline will be an additional cost.

Our staff and doctors work together making additional efforts to ensure the longevity and quality of crowns and bridges. We want you to be happy with the service you receive and ask you to refer your family and friends.

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Restoration Shade Confirmation

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Restoration Shade Confirmation

I,
, selected the shade of the restoration to be placed in my mouth. The shade that I chose is:
for tooth #:

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth.

I understand that once the restoration is made in the shade I chose, it can not be changed unless I pay an additional fee of $250 (two hundred and fifty dollars) per tooth.

Additionally, I understand that I am starting a process to receive a restoration in my mouth. This process is in phases. I understand the first phase, today, the tooth will be prepped and I will have a temporary restoration placed. I further understand that I may be wearing temporary restoration for a few weeks, which may come off. I must be careful to ensure that it is kept on until the permanent is placed. If the temporary crown/bridge comes off, I understand I must return as soon as possible for replacement. A lost or malfitting temporary crown/bridge can lead to gum disease, sensitivity or decay and may need to have the crown/bridge redone at an additional cost.

I understand that the final phase is the cementation of the permanent restoration. I also understand that this permanent cementation must be done within 90 (ninety) days. If placement is done after 90 (ninety) days, I understand there may be a chance the permanent restoration may not fit due to a shift or change of the teeth and/or gum tissues. I understand that if I wait for placement after the 90 (ninety) days and the restoration does not fit, I may need to pay an additional fee of $300 (three hundred dollars) per tooth.

Our staff and doctors work together making additional efforts to ensure the longevity and quality of crowns and bridges. We want you to be happy with the service you receive and ask you to refer your family and friends.

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Partial Denture Delivery

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Partial Denture Delivery

I,
understand that the partial denture was made in the ideal teeth shape and size to match my current arch, dentition or facial structure. I have had a chance to either confirm with the office in detail, my appearance and fit desires or to try the denture in was and approve the appearance and fit prior to processing.

I understand that the new partial denture is processed and any aesthetic changes will be an additional cost.

I understand that adjustments may be necessary for a better fit due to changes of bone and gum tissue.

Our staff and doctors work together making additional efforts to ensure the longevity and quality of dentures, I understand I am picking up my processed denture and will contact the dental office for any adjustments needed. The adjustments are at no charge for the next 60 (sixty) days.

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Endodontic Therapy Informed Consent

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  1. I, THE UNDERSIGNED, VOLUNTARILY CONSENT to McDuffie Dentistry, his/her (or its) partners, associates, administrative team, dental assistants, and/or staff providing the endodontic (root canal) therapy which has been recommended.
  2. I accept and understand that endodontic therapy is an attempt to save a tooth or teeth that might otherwise require extraction. I also accept and understand that endodontic therapy is used to correct an apparent problem and occasionally undiagnosed and/or hidden problems arise.
  3. I have been fully informed that endodontic therapy is not always successful as the tooth or teeth is/are already in jeopardy.
  4. I accept and understand that this endodontic therapy will not prevent future decay and/or possible fracture. I also accept and understand that the endodontic therapy may not prevent future problem with the tooth or teeth, as the tooth or teeth will be more brittle.
  5. The endodontic therapy has been fully explained to me, including all risks and complications involved. I have been fully informed that the risks and complications may include, but are not exclusive of:
    • Perforation of the canal with instruments which could result in the loss of the tooth and perhaps surgery.
    • Nerve or sinus damage causing temporary or permanent numbness of the chin, tongue or lips.
    • Instrument breakage in the canal that may require surgery.
    • Minor pain and/or swelling.
    • Replacement of existing restorations such as crown(s).
    • Temporary or permanent numbness.
    • The need for additional treatment, surgery and/or extraction.
    • The need for additional procedures on the tooth or teeth, such as crown(s).
    • Loss of the tooth or teeth.
  6. I have been fully informed that the condition of the tooth or teeth will worsen and that other systemic problems could develop if the procedure is not done.
  7. Iассеpt and understand there is NO WARRANTY or GUARANTEE as to any result and/or cure.
  8. I have had the opportunity to discuss the endodontic therapy, and have had an opportunity to ask questions, and am fully satisfied with the answers received.
  9. I accept and understand that I have the right to seek endodontic treatment from an American Dental Association-recognized specialist in endodontics.
  10. If, during the endodontic therapy, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.
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In-Office Tooth Whitening Treatment

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INFORMED CONSENT FORM IN-OFFICE TOOTH WHITENING TREATMENT

DESCRIPTION OF THE PROCEDURE

In-Office Whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. The In-Office Whitening treatment involves using the gel to producе maximum whitening results in the shortest possible time.

During the procedure the whitening gel will be applied to my teeth for two or three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel.

Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

RISKS OF TREATMENT

I understand that In-Office whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can be lightened from In-Office Whitening treatment. I understand that In-Office Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with stained teeth.

I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives.

I understand that the results of my In-Office Whitening cannot be guaranteed.

I understand that although my dentist/hygienist has been trained in the proper use of the In-Office Whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity is is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment.

After the whitening treatment, it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take home tray or repeating the whitening treatment.

I understand that the results of the whitening treatment is not intended to be permanent and secondary, repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces.

Since it is impossible to state every complication that may occur as a result of whitening treatments, the list of complications in this form is incomplete. The basic procedures of whitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my dentist/hygienist and my dentist/hygienist has answered all my questions to my satisfaction.

In signing this informed consent I am stating I have had this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my dentist and/or their staff.

SIGNATURES

By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for the In-Office whitening treatment to be performed on me.

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Implant Patient Information and Consent Form

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  1. I have been informed and I understand the purpose and the nature of this implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.
  2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an implant to help secure the replaced missing teeth.
  3. I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are inflammation of a vein, injury to the teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medicines used, etc.
  4. I understand that if nothing is done, any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth, followed by necessity of extraction. Also possible are temporomandibular joint (jaw) problems, headaches, referred pains to the back of the neck and facial muscles, and tired muscles when chewing.
  5. My doctor has explained that there is no method to accurately predict the gum and the bone healing capabilities in each patient following the placement of the implant.
  6. It has been explained that in some instances implants fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurance as to the outcome of results of treatment or surgery can be made.
  7. I understand that excessive smoking, alcohol, or sugar may effect gum healing and may limit the success of the implant. Agree to follow my doctor's home care instructions. I agree to report to my doctor for regular examinations as instructed.
  8. I agree to the type of anesthesia, depending on the choice of the doctor. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more until fully recovered from the effects of the anesthesia or drugs given for my care.
  9. To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites; anesthetics, pollen dust, blood, or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.
  10. I consent to photography, filming, recording, and x-rays of the procedure to be performed for the advancement of implant Dentistry, provided my identity is not revealed.
  11. I request and authorize medical/dental services for me, including implants and other surgery. I fully understand that during, and following the contemplated procedure, surgery, or treatment, conditions may become apparent which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modification in design, materials, or care, if it is felt this is for my best interest.
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Post-OP Instructions for Implants

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Healing following Dental Implant placement is usually fast and uncomplicated if you follow the directions below.

1. Often with Dental Implants there is very little bleeding. To control bleeding, Bite on gauze with firm pressure for 30-60 minutes or as directed, to encourage bleeding to clot. Remove the gauze and if site if still bleeding, replace with a new gauze, Repeat as necessary until heavy bleeding stops. Remember that Blood and saliva mix in the mouth and make it look like more bleeding than there actually is. The site could ooze for as long as 24-48 hours. Certain medications can make you bleed for longer periods. Elevate your head with a towel on your pillows to reduce bleeding and swelling. for If you notice Swelling and bruising, Ice packs can be used, 20 minutes on-20 minutes off, the first 24 hours.

2. If you wear or were given a removable prosthetic (Denture or Partial) we will give you specific instructions about wearing it while you heal.

3. We encourage no smoking for several months to ensure the long-term success of Dental Implants. Absolutely no smoking or use any Tobacco Products for at least 72 hours. Tobacco slows healing and increases the risk that you body will reject the implant(s)

4. Do not spit, suck on the wound or drink through a straw for 72 hours.

5. Do not rinse vigorously or spit, instead hold the rinse in your mouth and allow it to fall out gently. After the first week you can use warm salt water (1 tablespoon to a small glass of warm water) 2-3 times per day if necessary. Do not brush the area for 1 week or until directed. You can use a gauze or thin cloth to wipe the surrounding teeth if necessary.

6. Do not drink Alcoholic drinks (no Mouthwash unless directed), Carbonated drinks or Hot Drinks.

7. Avoid chewing until the numbness has wom off completely. For the first 48 hours chew on the opposite side and eat soft foods. Avoid spicy and crunchy foods such as chips, nuts, popcorn for 7 days.

8. Limit activities such as exercise, heavy lifting or activities that require you to bend for 48 hours. It is normal to experience some pain for several days after surgery.

If you were prescribed medications to control discomfort take it before the anesthetic has worn off, then as recommended or needed. You can also control pain with Over the Counter lbuprofen or Tylenol. If Antiblotics were prescribed take them as directed until gone, even if symptoms and signs of infection are gone. If Sutures were placed, you will be given an appointment to return or they will dissolve on their own. Some sutures may come out or change position while healing. This is normal

Please feel free to call us with any questions or concerns you may have at (919) 484-7478

Permanent Cementation of a Restoration

The permanent restoration was tried in my mouth and adjustments were made for comfort and fit. I,

was able to observe the appearance and how it feels within my mouth.

I now grant permission for the restoration to be cemented permanently. I understand that once it is cemented, I will not be able to make any changes to the restoration unless I pay an additional fee of $300 (three hundred dollars) per involved tooth

Our staff and doctors work together making additional efforts to ensure the longevity and quality of crowns and bridges. We want you to be happy with the service you receive and ask you to refer your family and friends.

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