I, ____________________________ of legal age and a resident of

_____________________________, do here by at test that Dr.

_______________________________________ has fully explained to me the dental procedure which I am
requesting for

I expressly warrant to the dental office that I am healthy, physically able and fit to undergo
the aforesaid dental procedure. I am informed that local anesthetic will be administered and I am
agreeable to it. I informed to Dr. ____________________________ that I am not taking any
medication/drugs or any form of medication.

I understand that, as the treatment proceeds, there may be a need to change the treatment plan
or additional treatments may be necessary ( or even after bridges and post have been done) such as
root canal treatments, extractions, surgical/periodontal treatments, additional posts, implants or TMJ
treatments and my case will be referred to a specialist. Implant/s was also suggested as an option.

I likewise understand that individual reactions to treatment vary and cannot be predicted, and
that I experience any unanticipated reactions during or following any treatment, I am obligated to
physically report to the dental clinic as soon as possible falling in which I shall not hold the dental
office liable.

In cases of root canal treatments, I am informed that root canal treated teeth may discolor and
may be brittle in time, fracture may occur.

I understand that the skeletal/ dental profile can not be altered or corrected by this procedure
and we can only improve the dental esthetics (color/contour).

I further understand that the success of the recommended treatment depends upon my entire
cooperation in keeping with scheduled appointments, following home care instructions, including oral
hygiene and dietary instructions, and reporting to the dental office any change in my health conditions
as soon as possible.

I hereby acknowledge that no guarantees or reassurances have been given or warranted to me

by anyone as to the results that may be obtained from the treatment, and is I want a new bridge/crown
fabricated ( ie change color, contour or length), I understand that I have to pay for a new set.
Additional treatment (such as veneers, bridge, crowns, dentures and fillings) are to be charged.

I am informed that if I would like to have the bridge, corwn, veneers and denture replace the
new ones done by your dental office, I am agreeable to pay for the second set in full amount also.

All of the above matters relating to the dental procedure to be performed on me, including its
process, life span, limitations, and the possible consequences have all been fully explained to me and
which I have fully understood, and all my queries in relation therewith have been answered to my full
satisfaction and understanding.

In view of the foregoing, I hereby authorize the dental office to commence and complete the
treatment as above described. I further hold the dental clinic, its owners, doctors, and employees free
and harmless from any liability for damages or injury that may arise from or maybe occasioned by the
performance of the dental procedure on me, and I will not commence or authorize the filling of any
suite in connection therewith as a consequence thereof.

Patients signature