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Dr Ivan Marx INC Consent Form

Informed Consent Form for General Dental Procedures

You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Please do not consent to treatment unless and until you have discussed potential benefits, risks, and complications with your dentist and all of your questions have been answered. By consenting to treatment, you acknowledge your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre- and post-treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

If you are a woman on oral contraceptive medication, you must consider the fact that antibiotics might make oral contraceptives less effective. Please consult with your physician before relying on oral contraceptive medication if your dentist prescribes, or if you are taking, antibiotics.

1. EXAMINATION AND X-RAYS
I understand that the initial visit may require radiographs in order to complete the examination, diagnosis, and treatment plan.

2. DRUGS, MEDICATION, AND SEDATION
I have been informed and understand that antibiotics, analgesics, and other medications can cause allergic reactions, including redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (a severe allergic reaction). They may cause drowsiness and a lack of awareness and coordination, which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anaesthetic medication and drugs that may have been given to me in the office for my treatment. I understand that failure to take medications prescribed for me in the manner prescribed may carry risks of continued or aggravated infection, pain, and potential resistance to effective treatment of my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives.

3. CHANGES IN TREATMENT PLAN
I understand that during treatment, it may be necessary to change or add procedures because issues found while working on teeth were not discovered during the initial examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any or all changes and additions as necessary.

4. TEMPOROMANDIBULAR JOINT DYSFUNCTIONS (TMJ)
I understand that symptoms of popping, clicking, locking, and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. However, symptoms of TMJ associated with dental treatment are usually temporary in nature and well tolerated by most patients. I understand that should the need for treatment arise, I will be referred to a specialist for treatment, the cost of which is my responsibility.

5. FILLINGS AND RESTORATIONS
I understand that care must be exercised when chewing on the new filling during the first 24 hours to avoid breakage, and that tooth sensitivity is a common after-effect of a newly placed filling.

6. REMOVAL OF TEETH (EXTRACTION)
An alternative to removal has been explained to me (root canal therapy, crowns, periodontal surgery, etc.), and I authorise the dentist to remove the following teeth and any others necessary for the reasons stated in paragraph #3. I understand that removing teeth does not always eliminate all infections if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which include pain, swelling, the spread of infection, dry socket, and loss of feeling in my teeth, lips, tongue, and surrounding tissue (paraesthesia) that can last for a period of time or a fractured jaw. I understand I may need further treatment by a specialist or even hospitalisation if complications arise during or following treatment, the cost of which is my responsibility.

7. CROWNS, BRIDGES, VENEERS, AND BONDING
I understand that sometimes it is not possible to match the colour of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily, and that I must be careful to ensure they are kept on until the permanent crowns are delivered. I realise that the final opportunity to make changes to my new crowns, bridge, or veneer (including shape, fit, size, placement, and colour) will be before cementation. It has been explained to me that, in very few cases, cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures.

8. DENTURES – COMPLETE OR PARTIAL
I realise that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The potential problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realise that the final opportunity to make changes to my new denture (including shape, fit, size, placement, and colour) will be at the 'teeth in wax' try-in visit. I understand that most dentures require relining approximately three to twelve months after placement. The cost of this procedure is not included in the initial denture fee.

9. ENDODONTIC TREATMENT (ROOT CANAL)
I realise there is no guarantee that root canal treatment will save my tooth and that complications can occur from the treatment. I understand that occasionally posts are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I also understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

10. PERIODONTAL TREATMENT
I understand that I have a serious condition causing gum inflammation and/or bone loss, which can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including non-surgical cleaning, gum surgery, and/or extractions. I understand that the success of treatment depends in part on my efforts to brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products, and adhere to other recommendations.

CONSENT:
I understand that dentistry is not an exact science; therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that I have requested and authorised. 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, apart from the treating dentist, is responsible for my dental treatment.

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of the recommended treatment with your dentist. Ensure that your dentist has addressed all of your concerns to your satisfaction before commencing treatment.

Informed Consent for Dental Implants

I. Recommended Treatment
I hereby give consent to the dentist to perform dental implant procedure(s) on me or my dependent, and any additional procedure(s) that may be considered necessary for my well-being based on findings made during the course of the recommended treatment. The nature and purpose of the recommended treatment have been explained to me, and no guarantee has been made or implied regarding the result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the recommended treatment. I also consent to the administration of local anaesthesia during the performance of the recommended treatment.

II. Treatment Alternatives
Alternative methods of treatment have been explained to me, such as bridges or loose dentures, but I wish to proceed with the recommended treatment described above.

III. Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anaesthesia, and the performance of the recommended treatment. These potential risks and complications include, but are not limited to, the following:
1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection, and/or bone infection. Bruising and/or swelling, delayed healing, and restricted mouth opening for several days or weeks.
3. Damage to adjacent teeth or tooth restorations.
4. Possible involvement of the sinus cavity and the creation of an opening from the mouth into the nasal or sinus cavity, which may require additional treatment or surgical repair at a later date.
5. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anaesthesia, resulting in altered or lost sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve over time, but in some cases, may be permanent.
6. Inability to place the implant due to local anatomy or implant failure.
7. Discolouration and appearance changes of the gum tissue or an unsatisfactory cosmetic result.
8. Bone loss around the implant(s) and/or adjacent teeth may result in the loss of the implant and/or adjacent teeth and may necessitate bone grafting jaw fracture.
9. As a result of the injection or use of anaesthesia, there may be swelling, jaw muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues. This is typically temporary, but in rare instances, it may be permanent.

Informed Consent for Bone Grafting

IV. Recommended Treatment
I hereby give consent to the Dentist to perform bone grafting procedure(s) on me or my dependent, and any additional procedure(s) that may be considered necessary for my well-being based on findings made during the course of the recommended treatment. The nature and purpose of the recommended treatment have been explained to me, and no guarantee has been made or implied as to the result or cure. I have been given satisfactory answers to all of my questions and wish to proceed with the recommended treatment. I also consent to the administration of local anaesthesia during the performance of the recommended treatment.

V. Treatment Alternatives
Alternative methods of treatment have been explained to me, such as a sinus lift, crown and bridge work, and tissue grafting. However, I wish to proceed with the recommended treatment described above.

VI. Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anaesthesia, and the performance of the recommended treatment. These potential risks and complications include, but are not limited to, the following:
1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection, and/or bone infection.
3. Bruising and/or swelling, delayed healing, and restricted mouth opening for several days or weeks.
4. Damage to adjacent teeth or tooth restorations.
5. Possible involvement of the sinus cavity and creation of an opening from the mouth into the nasal or sinus cavity, which may require additional treatment or surgical repair at a later date.
6. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anaesthesia, resulting in altered or loss of sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve over time, but in some cases, may be permanent.
7. Discolouration and appearance changes of the gum tissue or an unsatisfactory cosmetic result.
8. Failure, loss, infection, or rejection of the graft or membranes used to contain the graft.
9. If I have elected a banked bone or bone substitute graft, there is a rare chance of disease spreading from the processed bone.
10. Jaw fracture.
11. As a result of the injection or use of anaesthesia, there may be swelling, jaw muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary but, in rare instances, may be permanent.

Informed Consent for Minimal Oral Sedation

VII. Recommended Treatment
I hereby give consent to the dentist to perform minimal oral sedation procedures on me or my dependent and any such additional procedures as may be considered necessary for my well-being based on findings made during the course of the recommended treatment. The nature and purpose of the recommended treatment have been explained to me, and no guarantee has been made or implied as to the result or cure. I have been given satisfactory answers to all of my questions and wish to proceed with the recommended treatment. I also consent to the administration of local anaesthesia during the performance of the recommended treatment.

VIII. Treatment Alternatives
Alternative methods of treatment have been explained to me, such as general anaesthetic or no sedation, but I wish to proceed with the recommended treatment described above.

IX. Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anaesthesia, and the performance of the recommended treatment. These potential risks and complications include, but are not limited to, the following:
1. Drug reactions and side effects.
2. Atypical reaction to sedation medications, which may require emergency medical attention and/or hospitalisation.
3. Altered mental states.
4. Allergic reactions.
5. Nausea and/or vomiting.
6. As a result of the injection or use of anaesthesia, there may be swelling, jaw muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues. While these effects are typically temporary, they may, in rare instances, be permanent.

Informed Consent for Crown and Bridge Prosthetics

X. Recommended Treatment
I hereby give consent to the dentist to perform crown and bridge prosthetics procedures on me or my dependent and any such additional procedures as may be considered necessary for my well-being based on findings made during the course of the recommended treatment. The nature and purpose of the recommended treatment have been explained to me, and no guarantee has been made or implied as to the result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the recommended treatment. I also consent to the administration of local anaesthesia during the performance of the recommended treatment.

XI. Treatment Alternatives
Alternative methods of treatment have been explained to me, such as removable dentures or implants, but I wish to proceed with the recommended treatment described above.

XII. Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anaesthesia, and the performance of the recommended treatment. These potential risks and complications include, but are not limited to, the following:
1. Reduction of tooth structure.
2. Sensitivity of teeth.
3. Crown or bridge abutment teeth may require root canal treatment.
4. Breakage.
5. Uncomfortable or strange feelings, which are typically temporary. In limited situations, muscle soreness or tenderness of the jaw may persist following the placement of the prosthesis.
6. Unsatisfactory aesthetics or appearance.
7. Unsatisfactory longevity of crowns and bridges.
8. As a result of the injection or use of anaesthesia, there may be swelling, jaw muscle tenderness, or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues. While these effects are typically temporary, they may, in rare instances, be permanent.

Patient Informed Consent Agreement for POPI Act 4 of 2013 (POPIA), South Africa Addendum to Patient Information Form(s)

SUBJECT MATTER of this Agreement: Consent for the processing and use of personal information:

Herewith the undersigned, as indicated above (CAPACITY), consents to the processing of personal information by the Responsible Party (including practice staff and authorized third parties with whom the Practice has a service or contractual relationship) and as contemplated in the Protection of Personal Information Act No 4 of 2013 (POPIA), for the following purposes to:
Identify &/or verify the Data Subject’s required details
Treat & manage care in a dentist-patient-funder-insurance relationship (such as for pre-authorizations)
Assess products/services of interest to the treatment
Process data under this Agreement or for legal reasons
Communicate with other & relevant parties inasmuch it relates to treatment and care management
Communicate with Third Parties who contract to cover/ indemnify the patient for the costs of treatment or part thereof such as medical schemes/ administrators
Debt collection agencies / legal services for the purposes of recovering unpaid fees
Inform patients about Practice products, services & practice messages (such as via email / SMS / other means)
Process information necessary & in the legitimate interest of the practice, a third party to whom the information is supplied and the patient.

Should any other reason for disclosing information be required, the Practice will first obtain your permission.

Consent by PATIENT/ PARENT/ GUARDIAN/ GUARANTOR
By signing this Agreement, in my CAPACITY to sign, of my own free will without any undue influence from any person whatsoever, I consent to this Agreement.

In the event of me being a dependant, I confirm that I have the explicit permission of my Parent / Guardian / Guarantor - and vice versa - to consent & herewith, I indemnify the Practice against this not being the case. About Withholding Consent In my CAPACITY as Patient/ Parent/ Guardian/ Guarantor, I understand it is the policy of the practice to require the completion & signing of this consent Agreement. If you exercise your right to withhold such consent to the practice to collect & process such Personal Information, you understand & agree that in such case, the practice reserves the right not to provide dental services (except emergencies) and for which you in your CAPACITY take full responsibility and herewith indemnify the Practice.

Withdrawal of Consent
In my CAPACITY, I understand that I can withdraw this consent at any time & I undertake to inform the Practice of such withdrawal & in such case, I understand that this may affect my rights & contractual relationship with the Practice for which I take full liability and hereby indemnify the Practice should I opt for such action.

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Todays Date: 13 October 2024

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16 September 2024 4:17 pm SAST

Dr Ivan Marx INC Consent Form Uploaded by Dr Ivan Marx - admin@yourdentist.co.za IP 102.132.174.145

25 September 2024 12:54 pm SAST

Dr Ivan Marx - admin@yourdentist.co.za added by Dr Ivan Marx - admin@yourdentist.co.za as a CC'd Recipient Ip: 102.132.174.145