Consent Form

I understand that the placement of composite resin fillings, may entail certain risks. There is the possibility of failure to achieve the desired or expected results. I agree to assume these risks even if care and diligence is exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure of the filling, associated with, but not limited to, the following:

1. Sensitivity of teeth often after preparation for the placement of any restoration, the teeth may exhibit sensitivity. The sensitivity can be mild or severe. It may only last for a short period of time or for much longer. If such sensitivity is persistent or lasts for an extended period of time, notify the dentist because this can be a sign of more serious problems.
2. Risk of fracture Placement or replacement of any restoration is the possibility of the creation of small fracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear at a later time.
3. Necessity for root canal therapy – The preparation of the tooth often requires the removal of tooth structures to ensure that the diseased or otherwise compromised tooth structure provides a sound basis for placement of the restoration. Occasionally, this may lead to exposure or trauma to underlying nerve tissue. Should the nerve/pulp not heal, if you exhibit extreme sensitivity or an abscess contact us immediately. Root canal treatment or extraction may be required, at a separate cost to the filling.
4. Injury to the nerves - There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial tissues from any dental treatment, particularly those involving the administration of local anaesthetics. The resulting numbness that can occur is usually temporary, but in rare instances it could be permanent.
5. Aesthetics or appearance - When a composite filling is placed, effort will be made to closely approximate the appearance of natural tooth colour. However, because many factors affect the shades of teeth, it may not be possible to exactly match the tooth coloration. The shade of the composite fillings can change over time due to a variety of factors including mouth fluids, foods, smoking, etc. The dentist has no control over these factors.
6. Breakage, dislodgement, or bond failure Because of extreme pressures and other traumatic forces, it is possible for composite fillings or aesthetic restorations, to be dislodged or fractured. The resin enamel bond can fail, resulting in leakage and recurrent decay. The dentist has no control over these factors.
7. New technology and health issues Composite resin technology continues to advance, but some materials yield disappointing results over time and some fillings may have to be replaced by more improved materials. Some patients believe that having metal fillings replaced with composite fillings will improve their general health. This notion has not been proven scientifically and there are no promises or guarantees that the removal of silver fillings and the subsequent replacement with composite fillings will improve, alleviate or prevent any current or future health conditions.

5 Year Guarantee includes any fracture of crown, onlay, large fillings and bridge work, but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or de bonding (loosening) or subsequent need for root canal treatment. The guarantee is only valid for patients who attend Smile Rooms bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque, and food trapping. You must follow our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching, to prevent voiding this guarantee.

I UNDERSTAND that cosmetic bonding treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (Even though care and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or desired results nor the longevity of the treatment). We include a 2 year guarantee free of charge for patients at Smile Rooms, outlined at the end of this consent form.

I confirm that I am happy with the colour of my current teeth and do not wish for further whitening treatment to go any lighter. I understand that composite bonding is irreversible, once it is attached to the tooth it is very difficult to establish the junction between the filling and the tooth.

1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of bonding or composite veneers, it is necessary to slightly reduce or roughen the surface of the tooth to which the material may be bonded. This preparation will be done as conservatively as possible. If the veneer/bonding covering breaks or comes off, the uncovered tooth may become more decay susceptible. The tooth may require replacement with a veneer or crown.
2. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination.
3. Chipping, breaking or loosening of the veneer: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which a doctor has no control.
4. Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.
5. Aesthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of veneers which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences which may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition. In addition, under UV/black lighting the appearance of the Bonding may change or appear brighter compared to your natural tooth.
6. Longevity: it is impossible to place any specific time criteria on the length of time that veneers should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity. Please see our 2 year Guarantee below. I understand that cosmetic composite bonding discolours, and this is dependent on aftercare (e.g. diet, hygiene and the rate of staining of my teeth.
7. It is the patient’s responsibility to immediately inform the doctor and seek attention from him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling, and attending all appointments.

2 Year Guarantee includes any fracture of composite veneers/ bonding but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or de bonding (loosening) or subsequent need for root canal treatment.  The guarantee is only valid for patients who attend Smile Rooms bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque and food trapping. You also have followed our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching. 

If at any point you would like your bonding removed, this can be done. If you decide to have the bonding removed this will be at no extra cost to you, but you will only be eligible to receive a refund of up to 50% per tooth cost.
For example if you pay £280 per tooth you will be eligible for up to £160per tooth of bonding you have removed.

We include a 2 year guarantee free of charge for patients at Smile Rooms, outlined at the end of this consent form.

I confirm that I am happy with the colour of my current teeth and do not wish for further whitening treatment to go any lighter. I understand that composite bonding is irreversible, once it is attached to the tooth it is very difficult to establish the junction between the filling and the tooth. If you have been recommended straightening prior to bonding, the bonding will need to be removed and then completed again post straightening which will not be included in the cost.

1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of composite bonding, it is necessary to slightly reduce or roughen the surface of the tooth to which the material may be bonded. This preparation will be done as conservatively as possible. If the veneer/bonding covering breaks or comes off, the uncovered tooth may become more decay susceptible. The tooth may require replacement with a veneer or crown.
2. The sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination. After being complete the tooth may develop a condition known as pulpitis or pulpal degeneration. It is often necessary to do root canal treatments in these teeth.
3. Chipping, breaking or loosening of the composite: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which a doctor has no control.
4. Aesthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of the bonding which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences that may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition.
5. Longevity: it is impossible to place any specific time criteria on the length of time that bonding should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity. Please see our 1-year Guarantee below. I understand that cosmetic composite bonding discolours, and this is dependent on aftercare (e.g. diet, hygiene, and the rate of staining of my teeth.
6. It is the patient’s responsibility to immediately inform the dentist and seek attention from him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling and attending all appointments.

INFORMED CONSENT FOR COMPOSITE COSMETIC BONDING

I UNDERSTAND that cosmetic bonding treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (Even though care and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or desired results nor the longevity of the treatment). We include a 2 year guarantee free of charge for patients at Smile Rooms, outlined at the end of this consent form.

I confirm that I am happy with the colour of my current teeth and do not wish for further whitening treatment to go any lighter. I understand that composite bonding is irreversible, once it is attached to the tooth it is very difficult to establish the junction between the filling and the tooth.

1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of bonding or composite veneers, it is necessary to slightly reduce or roughen the surface of the tooth to which the material may be bonded. This preparation will be done as conservatively as possible. If the veneer/bonding covering breaks or comes off, the uncovered tooth may become more decay susceptible. The tooth may require replacement with a veneer or crown.
2. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination.
3. Chipping, breaking or loosening of the veneer: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which a doctor has no control.
4. Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.
5. Aesthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of veneers which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences which may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition. In addition, under UV/black lighting the appearance of the Bonding may change or appear brighter compared to your natural tooth.
6. Longevity: it is impossible to place any specific time criteria on the length of time that veneers should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity. Please see our 2 year Guarantee below. I understand that cosmetic composite bonding discolours, and this is dependent on aftercare (e.g. diet, hygiene and the rate of staining of my teeth.
7. It is the patient’s responsibility to immediately inform the doctor and seek attention from him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling, and attending all appointments.

2 Year Guarantee includes any fracture of composite veneers/ bonding but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or de bonding (loosening) or subsequent need for root canal treatment.  The guarantee is only valid for patients who attend Smile Rooms bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque and food trapping. You also have followed our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching. 

If at any point you would like your bonding removed, this can be done. If you decide to have the bonding removed this will be at no extra cost to you, but you will only be eligible to receive a refund of up to 50% per tooth cost.
For example if you pay £280 per tooth you will be eligible for up to £160per tooth of bonding you have removed.

I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGE WORK includes certain risks and possible unsuccessful results, with even the possibility of failure. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (even though care and diligence is exercised in the treatment of conditions requiring crowns and bridgework and fabrication of same, there are no promises or guarantees of anticipated results or the longevity of the treatment). We include a 5-year guarantee free of charge for patients at Reading Smiles, outlined at the end of this consent form.

1. Reduction of the tooth structure: In order to replace decayed or otherwise traumatised teeth, it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as practical. In preparation of teeth, anesthetics are usually needed. At times, there may be swelling, jaw muscle tenderness, or even a resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues which is usually temporary, or very rarely, permanent.
2. The sensitivity of teeth: Often, after the preparation of teeth or the reception of either crowns or bridges, the teeth may exhibit sensitivity. It may be mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If it is persistent, notify us inasmuch as this sensitivity may be from some other source.
3. Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatised from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly an extraction.
4. Breakage: Crowns and bridges may possibly chip or break. Many factors could contribute to this situation such as chewing excessively hard materials, changes in biting forces, traumatic blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes but the crowns/bridges may not actually break until chewing soft foods or possibly for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.
5. Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminate periods of time following placement of the prosthesis.
6. Aesthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in place prior to final cementation
7. The longevity of crowns and bridges: There are many variables that determine “how long” crowns and bridges can be expected to last. Among these are some of the factors mentioned in the preceding paragraphs. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity. Please see our 5-year Guarantee below.
8. It is a patient’s responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow any and all instructions, including the scheduling and attending all appointments. Failure to keep the cementation appointment can result in the ultimate failure of the crown/bridge to fit properly and an additional fee may be assessed.
9. Year Guarantee includes any fracture of the crown, Onlay, large fillings and bridgework, but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or debonding (loosening) or subsequent need for root canal treatment. The guarantee is only valid for patients who attend Reading Smiles bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque, and food trapping. You also have followed our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching.

I UNDERSTAND THAT REMOVABLE PROSTHETIC APPLIANCES (PARTIAL DENTURES and FULL ARTIFICIAL DENTURES) include risks and possible failures associated with such dental treatment. I agree to assume those risks and possible failures associated with, but not limited to, the following: (even though the utmost care and diligence is exercised in preparation for, and fabrication of, prosthetic appliances, there is the possibility of failure with patients not adapting to them):

- Failure of full dentures: there are many variables which may contribute to this possibility, such as:

1. Gum tissues which cannot bear the pressures placed upon them resulting in excessive tenderness and sore spots;
2. Jaw ridges which may not provide adequate support and/or retention;
3. Musculature in the tongue, the floor of the mouth, cheeks, etc., which may not adapt to and be able to accommodate the artificial appliances;
4. Excessive gagging reflexes;
5. Excessive saliva or excessive dryness of the mouth;
6. General psychological and/or physical problems interfering with success.

- Failure of partial dentures: Many variables may contribute to unsuccessful utilizing of partial dentures (removable bridges). The variables may include those problems related to the failure of full dentures, in addition to:

1. Natural teeth to which partial dentures are anchored (called abutment teeth) may become tender, sore, and/or mobile;
2. Abutment teeth may decay or erode around the clasps or attachments;
3. Tissues supporting the abutment teeth may fail.

I have had the purpose, benefits, reasonable risks, and alternatives, if any, to the procedure(s) explained to me. I have been given the opportunity to ask questions.

The wound may be closed with dissolving stitches. Home care instructions and required prescriptions will be provided after the extraction. It may take five to seven (5 -7) days for my mouth to feel comfortable, and another two to four (2- 4) weeks for the tissue around the site to heal completely.

I hereby authorise my dentist at Smile Rooms to perform the aforementioned procedure(s) necessary to my dental treatment, and any additional treatment procedures as are considered immediately necessary on the basis of findings during the above-mentioned treatment.

Gums or tissues involved in the anaesthetic injection may be sore for several days following treatment. Swelling of the tissues around the injection site is possible and can be treated by applying pressure and cold (ie. ice packs) the day of treatment to the area of swelling for a minimum of 1 -2 minutes. In addition, if anaesthetic involves the lower jaws, there may be difficulty opening the jaw for the first few days. The soreness and stiffness will dissipate with time but warm salt water rinses or moist heat on the side of treatment will facilitate healing. Transient facial paralysis is a rare possibility upon anaesthetic injection, but it will almost always resolve itself without any future consequences.

I understand that the placement of composite resin fillings, may entail certain risks. There is the possibility of failure to achieve the desired or expected results. I agree to assume these risks even if care and diligence is exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure of the filling, associated with, but not limited to, the following:

1. Sensitivity of teeth often after preparation for the placement of any restoration, the teeth may exhibit sensitivity. The sensitivity can be mild or severe. It may only last for a short period of time or for much longer. If such sensitivity is persistent or lasts for an extended period of time, notify the dentist because this can be a sign of more serious problems.
2. Risk of fracture Placement or replacement of any restoration is the possibility of the creation of small fracture lines in the tooth structure. Sometimes these fractures are not apparent at the time of removal of the tooth structure and/or the previous fillings and placement or replacement, but they can appear at a later time.
3. Necessity for root canal therapy – The preparation of the tooth often requires the removal of tooth structures to ensure that the diseased or otherwise compromised tooth structure provides a sound basis for placement of the restoration. Occasionally, this may lead to exposure or trauma to underlying nerve tissue. Should the nerve/pulp not heal, if you exhibit extreme sensitivity or an abscess contact us immediately. Root canal treatment or extraction may be required, at a separate cost to the filling.
4. Injury to the nerves - There is a possibility of injury to the nerves of the lips, jaws, teeth, tongue or other oral or facial tissues from any dental treatment, particularly those involving the administration of local anaesthetics. The resulting numbness that can occur is usually temporary, but in rare instances it could be permanent.
5. Aesthetics or appearance - When a composite filling is placed, effort will be made to closely approximate the appearance of natural tooth colour. However, because many factors affect the shades of teeth, it may not be possible to exactly match the tooth coloration. The shade of the composite fillings can change over time due to a variety of factors including mouth fluids, foods, smoking, etc. The dentist has no control over these factors.
6. Breakage, dislodgement, or bond failure Because of extreme pressures and other traumatic forces, it is possible for composite fillings or aesthetic restorations, to be dislodged or fractured. The resin enamel bond can fail, resulting in leakage and recurrent decay. The dentist has no control over these factors.
7. New technology and health issues Composite resin technology continues to advance, but some materials yield disappointing results over time and some fillings may have to be replaced by more improved materials. Some patients believe that having metal fillings replaced with composite fillings will improve their general health. This notion has not been proven scientifically and there are no promises or guarantees that the removal of silver fillings and the subsequent replacement with composite fillings will improve, alleviate or prevent any current or future health conditions.

5 Year Guarantee includes any fracture of crown, onlay, large fillings and bridge work, but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or de bonding (loosening) or subsequent need for root canal treatment. The guarantee is only valid for patients who attend Smile Rooms bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque, and food trapping. You must follow our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching, to prevent voiding this guarantee.

I have been educated and informed regarding the following oral surgery procedure(s):

for which I am giving my consent and I understand the risks that are involved in performing this procedure. Specifically, I have been informed that:

1. there is a risk of temporary or permanent anaesthesia/paraesthesia to my lower lip(s). This means that my lip may remain numb even after the procedure. Attempts to correct this involve special additional procedures.
2. postoperative bleeding is a normal consequence of this procedure, however, there are occasional instances that a patient's blood does not clot normally. In this case, additional care by the dentist or a physician may be necessary.
3. some swelling may occur due to the trauma and this might result in bruising.
4. because of the trauma to a surgical site, this site may later become infected and require additional care. I agree to take the antibiotics prescribed to me in the manner I was informed so as to minimise this
possibility. (Females) Antibiotics can interfere with birth control therapy.
5. bone fragments may later dislodge from the surgical site and need to be removed.
6. during procedures in the maxillary (upper) jaw, the maxillary sinus may perforate and require additional treatment to be repaired.
7. Adjacent teeth can be effected by oral surgery procedures. Adjacent teeth with decay can break. Weak crowns can pop off or break and teeth with large fillings can break. This may require additional treatment.
8. Additional potential complications described (if necessary ):

Incisal sculpting is a cosmetic procedure to shape and smooth worn and chipped teeth. This involves the removal of sound enamel (part of tooth).

This can result in temporary sensitivity. Once enamel has been taken away it CANNOT be replaced.

The procedure is carried out to enhance the appearance of the teeth.

I UNDERSTAND that treatment of dental conditions requiring INLAYS/ONLAYS include certain risks and possible unsuccessful results, with even the possibility of failure. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (even though care and diligence is exercised in the treatment of conditions requiring inlays/onlays and fabrication of same, there are no promises or guarantees of anticipated results or the longevity of the treatment). We include a 5-year guarantee free of charge for patients at Smile Rooms, outlined at the end of this consent form.

1. Reduction of the tooth structure: In order to replace decayed or otherwise traumatised teeth, it is necessary to modify the existing tooth or teeth so that inlays/ onlays may be placed upon them. Tooth preparation will be done as conservatively as practical. In preparation of teeth, anaesthetics are usually needed. At times, there may be swelling, jaw muscle tenderness or even a resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues which is usually temporary, or very rarely, permanent.
2. Sensitivity of teeth: Often, after the preparation of teeth or the reception of either inlays/ onlays, the teeth may exhibit sensitivity. It may be mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If it is persistent, notify us inasmuch as this sensitivity may be from some other source.
3. Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatised from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.
4. Breakage: Inlays/ onlays may possibly chip or break. Many factors could contribute to this situation such as chewing excessively hard materials, changes in biting forces, traumatic blows to the mouth, etc. Unobservable cracks may develop in inlays/ onlays from these causes but the inlay/Onlay may not actually break until chewing soft foods or possibly for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.
5. Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminate periods of time following placement of the prosthesis.
6. Aesthetics or appearance: Patients will be given the opportunity to observe the appearance of inlays/ onlays in place prior to final cementation.
7. Longevity of inlays or onlays: There are many variables that determine “how long” inlays/ onlays can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc., can affect longevity. Please see our 5-year Guarantee below.

Dentist: Dr Hanel Nathwani, Ankush Garg, Albert Gajdos, Radha Sisodia & Orthodontic Therapist

Device, treatment description and procedure: Invisalign developed by Align Technology, Inc. (“Align”) consist of a series of thin clear plastic, removable appliances (aligners) that move your teeth in small increments from their original position to a more aligned position. After undergoing a routine pre-treatment examination including x-rays and photographs, the dentist will take a scan of your teeth and send the scan along with a prescription to the laboratory. Sophisticated computer graphics and technology are used to develop a treatment plan which specifies the desired movements of your teeth during the course of your treatment. The technicians will create a Clincheck software model of your prescribed treatment and once approved by you a series of customised aligners are produced specifically for your treatment.

• Placement of attachments: Little composites of tooth coloured acrylic called attachments may be bonded to the front or the backside of specific teeth. This is to give your aligners more grip on your teeth when aiming to move them up or down, changing their tilt, or straightening them into position. They should only be removed by your orthodontist/dentist.
• Enamel removal/reduction: Interproximal enamel reduction or removal of the width of teeth is often part of the treatment to remove a slight amount of the enamel between the teeth using a high-speed drill and sandpaper in strips of 0.1-0.5mm from the mesial and distal surfaces of the premolar, molars and canines bilaterally as required. This creates space for the correction of crowded teeth or to enable the teeth in each jaw to come together more efficiently. No anaesthetic is required.
• Aligner Wear time: Most patients wear the aligners in pairs, (upper and lower arch teeth), unless undertaking single arch treatment. The aligner/s is/are worn in sequence and is/are individually numbered. Verbal or written instructions will be given by the dentist/orthodontic therapist as appropriate. Unless otherwise instructed by your dentist, you should wear your aligners for approximately 20 to 22 hours a day, as advised/or for about 2-3 weeks removing them only to eat, brush and floss and switch to the next aligners in the series. Treatment duration and total number of aligners worn varies depending on the complexity of your dentist’s prescription.
• Appointments and treatment duration: Unless instructed otherwise, follow-up with your Dentist or the Orthodontic Therapist every 6-8 weeks. Total treatment time averages 9-18 months (average number of aligners worn 18-30) but both will vary from person to person. Individuals vary considerably in their response to tooth alignment treatment, so the treatment time will be more or less than our estimate. Exact time predictions cannot be made. Poor cooperation in wearing the aligners or auxiliary elastics for the required hours per day, poor oral hygiene, lost aligners, missed appointments, and other factors can lengthen the treatment time and can dramatically affect the quality of the end result.
• Result of Treatment: Everyone is different, response to treatment is unpredictable. Invariably the teeth fail to move in a predictable way. If your treatment fails or either you or the dentist is not satisfied with the progress, then the dentist reserves the right and may recommend you see a specialist or an orthodontist (at any time or stage of your treatment without refunding any costs incurred until that point). Once your teeth are in the correct position we will then need to determined if we need to sculpt or add composite bonding or veneers at an extra cost (sculpting is included)
• Retention: VERY IMPORTANT: With all alignment treatments, there is a high chance that the teeth have a tendency to rebound to their original positions or shift their position after brace treatment. The type of retainer (Permanent or removable OR both) is discussed at the end of treatment. Any lost retainers must be reported immediately, as laboratories may require 3-14 days to supply a new retainer. An appointment for impressions may be required. Additional charge for any replacement retainers (e.g. lost, misplaced, damaged or broken) is applicable. Any delay can affect the movement of your teeth which can only then be corrected by re-doing the treatment with a new treatment plan and further costs.
• • Final Stability of teeth: The teeth and jaw structure are a system that is constantly changing throughout one’s life. Retainers that patients wear will enhance the stability of the final result and minimise changes but does not make a patient immune to this process. This will require you to wear retainers for 3-6 months full time- there after in the evening. Maturity changes that occur after active alignment treatment may alter the quality of the end result. If a patient decides to stop wearing their retainers at any point, their teeth may change and some of the original problems may re-emerge which can only be corrected through alignment treatment and additional costs.
• Mid-Course Correction: Even if the treatment goes broadly to plan, usually some refinement is needed at the end of treatment. A new scan may be taken for a new set of aligners. This is known as mid-course correction and can further lengthen the overall treatment time. Risks/Inconveniences unexpected problems and considerations
• Injury from Aligners: Aligners are designed to have minimal amount of injury potential and maximum amount of strength. Accidents, nevertheless, can occur. It is also possible for a patient to swallow or inhale parts of the appliance/s or attachments. The cheeks, lips and gums may be scratched or irritated by the position occasionally.
• Soreness & Discomfort: Some discomfort is expected, however due to the gentle but steady alignment forces generated, the appliances are easily tolerated. Paracetamol or ibuprofen may be taken to relieve this with your General practitioner’s consent. If you feel more than normal pressure of discomfort, or the soreness prohibits eating even soft food, please call for an appointment so any necessary adjustments may be made.
• Speech: The invisible Aligner may temporarily affect speech and may or may not result in a lisp, you will however acclimate to the appliances over time and effected speech will improve.
• Tooth decay, Decalcification, Periodontal Disease: Bacteria present in plaque release acids that draw calcium and phosphorous out of the outer surface of the teeth. Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush or floss their teeth properly before wearing the aligner. Patients undergoing treatment should minimise the amount and frequency of sugar in their diets. Hygiene Treatment is recommended and can be arranged.
• Jaw Joint: It is important that we are told about Temporary Mandibular joint/Jaw problems so that we can deal with them appropriately and promptly. There are some patients who will develop popping/clicking or other problems in their jaw joint during or after treatment. This is very rare. Please keep us informed if you have any concerns.
• A tooth may become ankylosed (tightly bound): occasionally, to its surrounding bone. It may not be possible to move the tooth at all. A change in the plan of treatment may become necessary and the costs may differ.
• Enamel wear: The tooth’s enamel surface is made up of a crystalline structure and like other crystals, it can have undetected fracture lines and defects within it. The enamel may also erode when a patient grinds their teeth to an excessive extent.
• Oral Surgery: Tooth removal or orthodontic surgery (jaw surgery) is sometimes necessary in conjunction with alignment treatment, especially to correct severe jaw misalignments/imbalance or crowding. These procedures will only be recommended if it improves the prospects for successful treatment.
• Root Resorption: Usually this effect is mild and does not compromise the teeth. However, sometimes this root resorption can be extensive and may then endanger the teeth. It is recognised that some patients are prone to this happening and some are not. It is not possible to predict which teeth might be affected. The dentist may recommend to take regular progress x-rays of their patient’s teeth during the treatment process to evaluate whether root resorption is occurring. Example: Alignment forces can innate a cellular response in the supporting tissues surrounding the roots of the teeth. It is this cellular response that allows the teeth to move. Sometimes this response becomes confused resulting in the damage to the ends of the roots of the teeth.
• Use of Tobacco: It is proven that tobacco reduces the blood flow to the tissues of the mouth, at a time when, good blood flow is needed for tooth movement. We recommend that all tobacco users cease the practice of tobacco use and seek advice from their orthodontist/dentist or General Practitioner (GP).

Benefits: Aligners offer an aesthetic alternative to conventional braces as they do not have the metal wires or brackets associated with conventional braces. Aligners are nearly invisible so many people won’t realise you are in treatment. No metal or wires usually means less time is spent at the dental practice having adjustments made. Tooth movement can be visualised through the Clincheck software. Aligners allow for normal brushing and flossing tasks that are generally impaired by conventional braces.

General: Please note that any additional dental treatment aside from Invisalign that becomes necessary during OR following your Invisalign treatment will be a separate cost. The deposit of £1,200 or as agreed for i7, Lite or single arch treatment is the cancellation fee charged regardless by Invisalign’ s laboratory and therefore non-refundable once the aligners have been approved. Once you have chosen your referred payment method, if you are spreading the cost of treatment using direct debit, if any payments are missed for any reason these must be paid prior to your next appointment in order to dispense your next set of aligners. In an unforeseen event of dentist not being able to treat you due to some emergency or personal reason, we will make suitable arrangements for you to be seen by another practitioner.

• Placement of attachments: Little composites of tooth coloured acrylic called attachments may be bonded to the front or the back side of specific teeth. This is to give your aligners more grip on your teeth when aiming to move them up or down, changing their tilt, or straightening them into position. They should only be removed from by your orthodontist/dentist. Under UV/Black lighting the appearance of the attachments may change or appear brighter than normal.
• Enamel removal/reduction: Interproximal enamel reduction or removal of the width of teeth is often part of the treatment to remove a slight amount of the enamel between the teeth using a high-speed drill and sandpaper in strips of 0.1-0.5mm from the mesial and distal surfaces of the premolar, molars and canines bilaterally as required. This creates space for the correction of crowded teeth or to enable the teeth in each jaw to come together more efficiently. No anaesthetic is required.
• Aligner Wear time: Most patients wear the aligners in pairs, (upper and lower arch teeth), unless undertaking single arch treatment. The aligner/s is/are worn in sequence and is/are individually numbered. Verbal or written instructions will be given by the dentist/orthodontic therapist as appropriate. Unless otherwise instructed by your dentist, you should wear your aligners for approximately 20 to 22 hours a day, as advised/or for about 2-3 weeks removing them only to eat, brush and floss and switch to the next aligners in the series. Treatment duration and total number of aligners worn varies depending on the complexity of your dentist’s prescription.
• Appointments and treatment duration: Unless instructed otherwise, follow-up with your Dentist or the Orthodontic Therapist every 6-8 weeks. Total treatment time averages 9-15 months (depends on type of Invisalign package) but both will vary from person to person. Individuals vary considerably in their response to tooth alignment treatment, so the treatment time will be more or less than our estimate. Exact time predictions cannot be made. Poor cooperation in wearing the aligners or auxiliary elastics for the required hours per day, poor oral hygiene, lost aligners, missed appointments, and other factors can lengthen the treatment time and can dramatically affect the quality of the end result.
• Result of Treatment: Everyone is different, response to treatment is unpredictable. Invariably the teeth fail to move in a predictable way. If your treatment fails or either you or the dentist is not satisfied with the progress, then the dentist reserves the right and may recommend you see a specialist or an orthodontist (at any time or stage of your treatment without refunding any costs incurred until that point).
• Retention: VERY IMPORTANT: With all alignment treatments, there is a high chance that the teeth have a tendency to rebound to their original positions or shift their position after brace treatment. The type of retainer (Permanent or removable OR both) is discussed at the end of treatment. Any lost retainers must be reported immediately, as laboratories may require 3-14 days to supply a new retainer. An appointment for impressions may be required. Additional charge for any replacement retainers (e.g. lost, misplaced, damaged or broken) is applicable. Any delay can affect the movement of your teeth which can only then be corrected by re-doing the treatment with a new treatment plan and further costs.
• Final Stability of teeth: The teeth and jaw structure are a system that is constantly changing throughout one’s life. Retainers that patients wear will enhance the stability of the final result and minimise changes but does not make a patient immune to this process. Maturity changes that occur after active alignment treatment may alter the quality of the end result. If a patient decides to stop wearing their retainers at any point, their teeth may change and some of the original problems may re-emerge which can only be corrected through alignment treatment and additional costs.
• Mid-Course Correction: Even if the treatment goes broadly to plan, usually some refinement is needed at the end of treatment. A new scan may be taken for a new set of aligners. This is known as mid-course correction and can further lengthen the overall treatment time.

Risks/Inconveniences unexpected problems and considerations

• Injury from Aligners: Aligners are designed to have minimal amount of injury potential and maximum amount of strength. Accidents, nevertheless, can occur. It is also possible for a patient to swallow or inhale parts of the appliance/s or attachments. The cheeks, lips and gums may be scratched or irritated by the position occasionally.
• Soreness & Discomfort: Some discomfort is expected, however due to the gentle but steady alignment forces generated, the appliances are easily tolerated. Paracetamol or ibuprofen may be taken to relieve this with your General practitioner’s consent. If you feel more than normal pressure of discomfort, or the soreness prohibits eating even soft food, please call for an appointment so any necessary adjustments may be made.
• Speech: The invisible Aligner may temporarily affect speech and mayor may not result in a lisp, you will however acclimate to the appliances over time and effected speech will improve.
• Tooth decay, Decalcification, Periodontal Disease: Bacteria present in plaque release acids that draw calcium and phosphorous out of the outer surface of the teeth. Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush or floss their teeth properly before wearing the aligner. Patients undergoing treatment should minimise the amount and frequency of sugar in their diets. Hygiene Treatment is recommended and can be arranged.
• Jaw Joint: It is important that we are told about Temporary Mandibular joint/Jaw problems so that we can deal with them appropriately and promptly. There are some patients who will develop popping/clicking or other problems in their jaw joint during or after treatment. This is very rare. Please keep us informed if you have any concerns.
• A tooth may become ankylosed (tightly bound): occasionally, to its surrounding bone. It may not be possible to move the tooth at all. A change in the plan of treatment may become necessary and the costs may differ.
• Enamel wear: The tooth’s enamel surface is made up of a crystalline structure and like other crystals, it can have undetected fracture lines and defects within it. The enamel may also erode when a patient grinds their teeth to an excessive extent
• Oral Surgery: Tooth removal or orthodontic surgery (jaw surgery) is sometimes necessary in conjunction with alignment treatment, especially to correct severe jaw misalignments/imbalance or crowding. These procedures will only be recommended if it improves the prospects for successful treatment.
• Root Resorption: Usually this effect is mild and does not compromise the teeth. However, sometimes this root resorption can be extensive and may then endanger the teeth. It is recognised that some patients are prone to this happening and some are not. It is not possible to predict which teeth might be affected. The dentist may recommend to take regular progress x-rays of their patient’s teeth during the treatment process to evaluate whether root resorption is occurring. Example: Alignment forces can innate a cellular response in the supporting tissues surrounding the roots of the teeth. It is this cellular response that allows the teeth to move. Sometimes this response becomes confused resulting in the damage to the ends of the roots of the teeth.
• Use of Tobacco: It is proven that tobacco reduces the blood flow to the tissues of the mouth, at a time when, good blood flow is needed for tooth movement. We recommend that all tobacco users cease the practice of tobacco use and seek advice from their orthodontist/dentist or General Practitioner (GP).

Dear ,

I trust that you have read our consent form, for the Invisalign treatment for Neha. I would like to make sure you’re aware of all possible health scenarios if you wish to proceed with Invisalign treatment.

All issues mentioned within the consent form could apply to you as a result of Invisalign treatment, but we would especially like to make sure you understand the following risks are more likely to occur. Everyone is different, and the response you may show to treatment is unpredictable.

As shown to you, on Your Invisalign Clin-check, your overjet will not be fully corrected although there will be an improvement. We recommend, the most ideal treatment would be, jaw surgery along with orthodontic treatment by a specialist. If your treatment fails or either you or the dentist is not satisfied with the progress, then the dentist reserves the right and may recommend you see a specialist. (At any time or stage of your treatment without refunding any costs incurred until that point).

Root Resorption: Usually this effect is mild and does not compromise the teeth. However, sometimes this root resorption can be extensive and may then endanger the teeth. It is recognised that some patients are prone to this happening and some are not. It is not possible to predict which teeth might be affected. Example: Alignment forces can innate a cellular response in the supporting tissues surrounding the roots of the teeth. It is this cellular response that allows the teeth to move. Sometimes this response becomes confused resulting in the damage to the ends of the roots of the teeth.

Tooth decay, Decalcification, Periodontal Disease: Bacteria present in plaque release acids that draw calcium and phosphorous out of the outer surface of the teeth. Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if you consume foods or beverages containing sugar, do not brush or floss your teeth properly before wearing your aligner. Patients undergoing treatment should minimise the amount and frequency of sugar in their diets. Hygiene Treatment is recommended and can be arranged.

Bone Loss can also occur when moving the teeth which can result in gum recession and the teeth becoming mobile in the future.

Teeth can also become non-vital during orthodontic treatment, which means the tooth has effectively died. This would result in the tooth/teeth needing root canal treatment which we cannot guarantee will save the tooth. Long term the tooth/teeth may also require extracting due to failed root canal treatment, however we cannot predict when/if this will occur.

This consent form is to make sure that you are fully informed about what is involved when having a PDO thread lifting treatment

1. I have been informed and I understand the purpose and nature of the PDO thread lifting procedure. I understand what is required to place the PDO threads.
2. My clinician has carefully examined the area of concern, and surgical and non-surgical alternatives to this treatment have been explained. I have considered these methods and I have elected thread lifting treatment.
3. I have been informed of the possible risks and complications.
4. My clinician has explained that there is no method of accurately predicting any healing or the reproduction of collagen in each individual patient following the PDO thread lifting procedure and therefore only an estimated time can be given for the lasting effect of this procedure.
5. I confirm that I understand to retain the optimum lifting effect of the PDO thread lifting treatment, I will need Botulinum toxin (Botox) injections around every 6- 9 months to relax the depressor muscles that pull down the face against the action of the threads.
6. I understand that excessive smoking and alcohol intake may affect any healing and may limit the success of the long term effects.
7. I consent to the photography of procedures for my records and the advancement of PDO thread lifting and I understand that these photographs will be stored in accordance with data protection legislation and will not be used in any publications without my prior consent.

I UNDERSTAND that porcelain veneer treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results and/or failure associate with, but not limited to the following: (Even though care and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or desired results nor the longevity of the treatment). We include a 5-year guarantee free of charge for patients at Smile Rooms, outlined at the end of this consent form.

1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of porcelain veneers, it is necessary to slightly reduce or roughen the surface of the tooth to which the veneer(s) may be bonded. This preparation will be done as conservatively as possible. If the veneer covering breaks or comes off, the uncovered tooth may become more decay susceptible. The tooth may require replacement with another veneer or crown.
2. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination.
3. Chipping, breaking or loosening of the veneer: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which the doctor has no control.
4. Crowned or bridge abutment teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth. If teeth remain too sensitive for long periods of time following crowning, root canal treatment may be necessary. Infrequently, the tooth (teeth) may abscess or otherwise not heal which may require root canal treatment, root surgery, or possibly extraction.
5. Aesthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of veneers which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences which may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition.
6. Longevity: it is impossible to place any specific time criteria on the length of time that veneers should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity.
7. It is the patient’s responsibility to immediately inform the doctor and seek attention from him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling and attending all appointments.
8. It is the patient’s responsibility to attend a regular check up and hygiene appointments. Regular dental visits are essential for the maintenance of healthy teeth and gums which is even more important when having the porcelain veneers. The Smile Rooms reserves the right to waive the guarantee offered with the treatment if patient fails to attend a dental check ups and hygiene visits twice a year.

What are retainers?

Retainers are designed to hold your teeth in their corrected positions after the braces have been taken off or you have completed your Invisalign treatment. Orthodontic retainers are custom-made devices, usually made of clear plastic, that hold teeth in position after surgery or any method of realigning teeth.

Important Information about wearing retainers after brace treatment:

Retainers are extremely important, as the teeth will revert to their old positions if they are not retained after treatment. It is essential that the retainers are worn as directed, to ensure that this does not happen.

IT IS YOUR RESPONSIBILITY TO KEEP YOUR TEETH IN THEIR CORRECTED POSITIONS. If the retainers are not worn then your teeth may move and will not be ideally aligned.

Please note the following information.

The removable retainers are to be worn full time, day and night for AT LEAST 3 months.

Following this the retainer must be worn for at least 12 hours per day (mostly whilst sleeping) our advice would be to continue to wear the retainers on a lifelong basis to maintain the teeth in the corrected position following the first year of retainer wear.

If the retainers are lost, please contact the surgery immediately to have them replaced.

Instructions for cleaning and wear:

Remove retainers for EATING, CONTACT SPORTS, BRUSHING TEETH and keep safe in storage case. Clean them inside and out with a brush and water, then rinse in cold water. DO NOT CLEAN RETAINERS WITH HOT WATER! DO NOT USE toothpaste as this will make the retainers change colour. It is useful to clean your retainer regularly using a cleansing agent which may be purchased from the chemist or your orthodontist – ‘RETAINER BRITE’

Dr M Spanaki – DDS, MSc – Special Interest in Endodontics

For all appointments with Dr Marina Spanaki a deposit is required of £95. Dr Marina visits specifically for each appointment, I understand the deposit is non-refundable should I cancel less than 48 hours prior to my appointment or choose on the day not to proceed with treatment.

I understand that many factors contribute to the success of root canal treatment and not all factors can be determined in advance. This includes my resistance to infection, the bacteria causing the infection, the size, shape and location of the canals.

I understand that root canal treatment has a very high success rate, but no guarantee can be given for a perfect result. Treatment may not relieve my symptoms and treatment can occasionally fail for unexplained reasons.

Risks of Root Canal Treatment

• Inability to completely fill the root canal.
• Fracture or breakage of the root or crown during or after treatment.
• Inadvertent separation of files or instruments within the root canal system that are unable to be retrieved
• Perforation of the tooth during treatment.
• Damage to existing fillings, crowns or porcelain veneers
• Infection may reoccur and continue, requiring further treatment or extraction.
• Sodium hypochlorite accident when the antimicrobial solution that is used leaks out of the root canal system (although there are measures in place to considerably reduce this risk)

Alternatives to Root Canal Treatment

The most common alternative includes:

• Extraction - Further treatment may be required including replacement by an artificial tooth by means of a removable denture, fixed bridge, or dental implant.
• No Treatment – If I choose no treatment, my condition may worsen and I risk further symptoms, including severe pain, infection, swelling, and loss of this tooth.

CHANGES ON THE ROOT CANAL TREATMENTS DUE TO COVID-19

• Dentist and dental nurse in full PPE
• Consultations will be necessary before appointment for treatments
• The root canal treatment will be finished in one visit where possible which means a longer appointment of approximately 2hours
• The rubber dam (rubber sheet) will be covering the mouth and the nose during the whole time of the treatment.

I hereby authorize and request that smile rooms dental surgeons will perform corrective surgery on my jaw (maxilla). The operation is planned to implant a bone substitute material, into the floor of the sinus in the hope that new bone will be incorporated into the material so that an implant(s) might be placed. A second procedure will be needed to place the implant(s). It is hoped that the implants will become stable and act as anchors for fixed or fixed detachable bridges or dentures.

I have been informed and understand that occasionally there are complications of surgery, drugs, and anesthesia, including, but not limited to:

1. Pain, swelling, and postoperative discoloration of face, neck, and mouth.
2. Numbness and tingling of the upper lip, chin, gums, teeth check, and palate, which may be transient, but may be permanent.
3. Infection of the bone that might require further treatment, including hospitalization and surgery.
4. Malunion, delayed union or non-union of the synthetic bone replacement material to normal bone, or lack of adequate bone growth into the synthetic material.
5. Bleeding which may require blood transfusions or other extraordinary means to control.
6. Limitation of jaw function.
7. Stiffness of facial and jaw muscles.
8. Injury to the teeth.
9. Referred pain to the ear, neck, and head.
10. Postoperative complications involving the sinuses, nasal cavity, sense of smell, infraorbital regions, and altered sensations of the upper cheek and eyes.
11. Postoperative unfavorable reactions to drugs, such as nausea, vomiting, and allergy.
12. Possible loss of teeth and bone segments.
13. Possible bruising and/or discoloration of the face, usually of a temporary nature.

I have been educated and informed regarding the following oral surgery procedure(s): for which I am giving my consent and I understand the risks that are involved in performing this procedure. Specifically, I have been informed that:

1. There is a risk of graft migration or rejection, which may require further bone grating in this area.
2. There may be symptoms of sinusitis (pain/pressure), these are usually transient.
3. During this procedure, the maxillary sinus may perforate and require additional treatment to be repaired.
4. Bleeding is a normal consequence of this procedure, however, there are occasional instances that a patient's blood does not clot normally. In this case, additional care by the dentist or a physician may be necessary. Bleeding from your nose is normal.
5. The swelling will occur due to the trauma and this might result in bruising.
6. There is a risk of Infection which will require additional care. Taking the antibiotics prescribed will minimise this possibility. (Females - Antibiotics can interfere with birth control therapy)
7. Adjacent teeth can be affected by oral surgery procedures. Adjacent teeth with decay can break. Weak crowns can pop off or break and teeth with large fillings can break. There may be a risk to the nerves of the adjacent teeth. This may require additional treatment.

Patient Agreement and Informed Consent for Cosmetically

Focused Tooth Alignment

This Patient Agreement contains important information about your treatment. BY SIGNING THIS PATIENT AGREEMENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. Please read carefully and ask questions about any areas that are unclear:

Scope of Treatment: Our objective is to straighten your teeth, usually without significant bite change, in a reasonable time frame - usually 4-9 months. You may have aspects of your bite that will not be addressed with this treatment, such as, but not limited to, molar relationships/posterior cross bite, overjet, under jet, facial profile, TMJ problems, displaced tooth roots and midline discrepancies. Full correction of the items mentioned here can oftentimes involve years of orthodontic treatment. The goal of this cosmetically focused and short-term orthodontic treatment is to correct your chief cosmetic complaints, which you have shared with us. This treatment is not a replacement for traditional comprehensive orthodontic treatment. This cosmetically focused treatment is an alternative for people who are not interested in traditional comprehensive orthodontic treatment and are seeking a more cosmetically focused orthodontic treatment option that can be provided over a shorter period of time.

Hygiene: BRUSH YOUR TEETH, GUMS, braces and wires thoroughly after each meal and before going to bed. Poor oral hygiene can result in puffy, bleeding gums and permanent white spots on teeth. INFLAMMATION AND BLEEDING GUMS WILL DELAY YOUR TREATMENT. An interproximal brush is the best way to clean around your braces and can be purchased in any grocery store/drug store. Use this brush between your teeth at the gumline. We do reserve the right to suspend or delay treatment if your oral hygiene is poor. Keep your teeth and braces clean!

Hard Food: DO NOT EAT hard food such as popcorn, ice, caramels or hard candy. These foods can break the brackets. CUT UP foods such as meats, apples, carrots etc. before eating them. If any brackets de-bond from the teeth they can be re-cemented free of charge, if they have not been lost/broken. Lost/broken brackets will be replaced at a cost of £50 per bracket.

Soreness: After the braces are put on the teeth may be sore, usually for 2-4 weeks. Aspirin, Advil or Aleve may be taken to relieve this. If the soreness prohibits eating even soft food, please phone for an appointment so any necessary adjustments may be made. If the inside of the lip is sore, the wax that is provided can be used as a cushion over the braces until the lips become accustomed. Taking pain medication prior to your adjustment appointments can help minimize discomfort.

Jaw Joint: There are some patients who will develop a popping/clicking or other problem in their jaw joint during or after orthodontic treatment. This is very rare. Usually, orthodontic treatment provides a positive effect on the jaw joint. You should understand that pre-existing joint conditions can manifest as a popping or clicking after orthodontic treatment but orthodontic treatment by itself has not been shown to cause popping/clicking of the jaw joints.

Main Objective: I understand that the main objective of my orthodontic treatment is to align my teeth for cosmetic reasons. My bite and the relationship of my back teeth are not the focus of this treatment. 3-6 months may be required after treatment for the bite to settle and be completely comfortable. Significant changes in lip profile necessitate jaw surgery, which I am not seeking. I am aware of these objectives and limitations of short-term treatment. I fully understand that my course of treatment may not result in complete orthodontic correction. This is not mainstream orthodontic treatment philosophy and many orthodontists will disagree with this type of orthodontic treatment that does not aim to completely correct/change the bite relationship.

A Cephalometric X-ray will not be taken: A cephalometric x-ray is usually taken in association with traditional comprehensive orthodontics. This type of x-ray shows the relationship of the skull, skeleton and teeth. This type of x-ray does not provide us with essential information for performing cosmetic tooth alignment. Therefore, a cephalometric x-ray is not typically taken in association with cosmetic tooth alignment. By signing this consent form, you are communicating that you understand that this type of x-ray will not be part of your pre-treatment records. If you desire more information about this topic, please ask the dentist.

Technique: Space will be made by enamel reproximation (minor tooth reduction). This allows limited tooth movement in the area of the crowding. Rarely sensitivity is possible from this, but is transient and not common. Alternative treatment options to

enamel reproximation for making space include tooth extraction, which we only perform in extreme cases of crowding, and expanding the dental arch is proven to be unstable in adult patients. Upper and lower dental midlines will not be made to coincide for most cases as midline changes often require years of treatment. Misshaped and abnormally long teeth will be reshaped as part of

treatment. On occasion, bonding may be needed to provide an even appearance of the edges of front teeth whether because of stubborn tooth movement or misshaped teeth. Charges for bonding will be determined on a case-by-case basis.

Standard of Straightness: We seek to straighten teeth to a very high level with cosmetically focused orthodontic treatment. If, however, numerous custom requests arise which the doctor feels will take an inordinate amount of extra time or in fact may not even be possible to achieve, we reserve the right to refer you to an orthodontic specialist for conventional comprehensive, 2-year, bite-changing orthodontic treatment, without a refund of monies paid up until that point in treatment.

Retention: Teeth have a tendency to rebound to their original positions after orthodontic treatment. Very severe problems have a higher tendency to relapse, and the most common type of relapse occurs with twisted teeth. Retainers will be placed immediately to minimize relapse. Full cooperation in wearing these appliances (full time for 6 months, at night for 6 months, and every other night indefinitely) is essential and part time wear is required for years. There is a fee to replace lost retainers. There are both fixed and removable options for orthodontic retainers.

Disputes: Should any dispute arise regarding fees, treatment, its outcome, or other matters associated with treatment, I agree to seek resolution through arbitration (peer review process) in lieu of court in order to seek a speedy and fair resolution of such issues. By signing this consent form I am agreeing to handle any dispute that might arise as a result of treatment through a dental peer review process (arbitration).

Cleanings: You should have at least one professional cleaning during your treatment. If you have an appointment for a cleaning scheduled, keep it! This is not required but highly encouraged.

Appointments: Please keep your adjustment appointments! Missed appointments can result in delayed

completion. Please notify us at least 48 hours in advance should you need to reschedule since another patient may need this time slot. There will be a fee charged for all missed appointments or short notice cancels of £50. This fee will be payable before any further appointments can be booked. There are some visits that are required after your braces are off (retainer checks etc.). These visits are very important. Relapse, bite settling, and retainer or splint adjustments (or breakage) are just some of the items we wish to monitor in this stage.

Moving: If you plan on moving away during orthodontic treatment, it is usually advisable to complete treatment with our office. It would be difficult to change dentist during treatment.

Disclaimer and Release of Liability: I understand that the dentist who is providing my cosmetic tooth alignment is a general dentist, is not an orthodontist, and is not employed by, an agent of, affiliated with, or licensed by Six Month Smiles, Inc. Six Month Smiles provider status denotes only that a dental professional has completed the training course offered by Six Month Smiles, Inc. that is necessary to enable him or her to begin treating patients with the Six Month Smiles system. I understand that the certificate provided by Six Month Smiles, Inc. to my dentist attests only to my dentist’s attendance at, and completion of, the Six-Month Smiles training course and does not attest to, certify, or guarantee any level of skill or expertise or any quality of performance. I understand and acknowledge that Six Month Smiles, Inc. makes no warranties or representations regarding, and does not guarantee or certify the quality of, the services provided by my dentist or any other licensed health care professional.

As the dentist has informed you, we can improve the alignment of the teeth to the degree discussed.  

Diet – is the most important thing for your teeth to reach the optimum results. During the whitening process your teeth become porous and more susceptible to staining so that even one cup of tea will spoil the results! Its is best to avoid all foods that generally stain things such as tea, coffee, red wine, curries, soya sauce, tomato ketchup, beetroot, spinach, strawberries etc.

Note: Please keep whitening gel refrigerated

Step by step

1. Brush your teeth as normal before going to bed
2. Place the nozzle provided onto the syringe
3. Place a tiny drop of gel into the top 10 and bottom 10 teeth on your whitening trays
4. Place the trays into your mouth and wear overnight (6-10 hours)
5. Do this continuously for 7-10 days (or as prescribed by your dentist)

Expect your teeth to be sensitive to hot/cold and potentially wind, sometimes you may get sporadic twinges of sensitivity which is fairly normal and it will subside after the treatment is finished. If you are finding it that your teeth are very sensitive, you may want to place some Sensodyne toothpaste into the tray instead of the gel for a night before continuing with the gel.

White patches on the teeth tend to get whiter, this can be masked by either stopping the whitening or continue to bring the colour up to the rest of your tooth. White fillings/Crowns/bridges/veneers will not change colour so save yourself some gel by avoiding these areas inside your trays. Canines do not whiten as much as the other teeth due to them being thicker and naturally darker., so you may want to spend 2-3 days dedicated to just whitening these particular teeth. It is natural and normal for the whole tooth not to appear as one uniform colour, except a colour graduation throughout the tooth i.e. near the gums will appear darker, the middle will be lighter and the tips of the teeth will be the lightest.

The white Diet

Note: anything that will stain a white t-shirt will also stain your teeth.

Following the white diet is very important to help you achieve the best results from teeth whitening. It is advised that you keep to this diet during your whitening treatment and for approximately 48 hours after your whitening treatment is complete.

Forbidden foods

• Red meat – pork, lamb and beef or any other red meat products such as bacon or sausages
• Some seafood – Tuna, sardines, prawns, crab, crabsticks as these contain colourings
• Vegetables with colour – Beetroot, tomatoes, sweetcorn, carrots, peas, sprouts, asparagus, mushrooms
• Bread (excluding pitta) – White, brown, wholegrain, baguettes and pizza dough
• Pasta- Brown, wholegrain or coloured
• Breakfast cereals
• Chocolate and sweets
• Full fat milk
• Butter
• Beer, red wine, spirits (excluding vodka & gin)

Permitted Foods

• White meats – chicken & turkey. This must not be fried, or treated with coloured spices/sauces
• Boiled Rice & pasta- White with no seasoning & only white sauce
• Fruit- bananas
• Vegetables – White beans, cauliflower, cucumber with the skin peeled off
• Pitta bread
• Skimmed milk
• Vodka/gin with lemonade or soda/tonic water

If you need any help do not hesitate to contact the team here at Smile Rooms, we are here to guide you on your journey to whiter teeth

 This information has been given to me so that I can make an informed decision about having my white spots removed. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure.  

 This treatment is designed to remove white spots from teeth, such as the spots left behind from orthodontic brackets or from fluorosis.

 White spots are very common and can be caused by a range of factors including:  Icon which can restore the natural colour of your tooth with no need to drilling. This minimally invasive technique uses a process of infiltration to blend the white spots in with the rest of the tooth. Enables immediate treatment of lesions not yet advanced enough for restoration; ends “wait and see” approach. It Arrests caries/decay progress without unnecessary loss of healthy tooth structure, minimally invasive.

Risks Of Consent For Treatment

• Increased sensitivity
• May relapse to original form

Introduction

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discoloured and could be treated by in-office whitening (also known as “bleaching”) of my teeth.

Description Of The Procedure

Zoom! in-office tooth whitening is a procedure designed to lighten the colour of my teeth using a combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp. The Zoom! treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the Zoom! lamp for three (3), 15-minute sessions. 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 either the gel or light. Lip balm (SPF rating: 30+) may also be applied as needed and I will be provided an ultraviolet light filter 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.

Alternative Treatments

I understand I may decide not to have the Zoom! treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:

• Whitening Toothpaste/Gels Other
• In-office Whitening Treatments
• Take-Home Whitening Kits

Cost

I understand that the cost of my Zoom! treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my Zoom! treatment.

Risks Of Consent For Treatment

I also understand that Zoom! treatment results may vary or regress due to a variety of circumstances. I understand that almost all-natural teeth can benefit from Zoom! whitening treatments and significant whitening can be achieved in most cases. I understand that Zoom! whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with grey or bluish-grey teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives. 

I understand that Zoom! treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemotherapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that the Zoom! Lamp emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing Zoom! treatment.

I understand that the results of my Zoom! Treatment cannot be guaranteed.

I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the Zoom! 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/Pain – During the first 24 hours after Zoom! treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a Zoom! treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals.

People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open 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 Zoom! treatment.

Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips or cheek

margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or ultraviolet light.

Dry/Chapped Lips – The Zoom! treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream.

Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the Zoom! treatment.

Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my Zoom! treatment.

Root Resorption – This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.

Relapse – After the Zoom! treatment, it is natural for the teeth that underwent the Zoom! 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 Zoom! treatment. I understand that the results of the Zoom! Treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

The safety, efficacy, potential complications and risks of Zoom! treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of Zoom! treatment, the list of complications in this form is incomplete. The basic procedures of Zoom! treatment and the advantages and disadvantages, risks and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction.

In signing this informed consent, I am stating I have read 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 Zoom! treatment and that I agree to undergo the treatment as described by my dentist.

Signatures

Background the General Dental Council permits patients to directly access the services of dental hygienists from 1 May 2013. Previously, a dentist had to see a patient prior to prescribing hygiene treatment. This meant that you would have been examined to see whether you had oral problems that warranted further treatment or investigation.

Direct Access- You need to understand the scope of what a dental hygienist does and can’t do. A hygienist can see you to provide oral hygiene advice, remove stain, tartar, bacterial deposits, and other debris. In relation to gums, the hygienist can advise you on the progression of gum disease, but more advanced conditions need to be assessed by a dentist, and the hygienist then continues treatment under the prescription of the dentist. Dental hygienists can’t diagnose or give the prognosis (the likely outcome) of diseases such as decaying and broken teeth, or prescribe antibiotics, painkillers or any other drugs to alleviate symptoms.

Visits to your hygienist is not a substitute for full dental examinations. Referral to dentist If the hygienist advises you to see a dentist, it is because they feel that it is in the interests of your health, it is outside the scope of what they are allowed to do, or they are uncertain about treating you without further advice. There are very rare circumstances when a hygienist can’t start treatment, and before they are prepared to continue, insist that a dentist assesses you. These may relate to your medical history and general health, or the condition of your mouth, which gives them concern.

Patient Informed Consent – Please read carefully: I have read and understand the limitations of direct access to a dental hygienist and agree to be treated under the direct access arrangements. I understand that the hygienist is not responsible for the overall health of my mouth and that regular visits to a dentist are still required.

Informed Consent for Tooth Extraction (Removal) Including Wisdom Tooth Extraction

Extraction of the upper molar and wisdom teeth

Extraction of lower wisdom teeth

RISKS:

WHERE YOUR DENTIST HAS CONCERNS ABOUT THE POSITION AND PROXIMITY OF THE NERVE IN THE LOWER JAW YOU MAY BE ASKED TO HAVE A CT SCAN TO CLEARLY IDENTIFY THIS NERVE. WITHOUT WHICH YOU MAY BE AT RISK OF NERVE DAMAGE. YOUR DENTIST WILL ADVISE YOU IF THEY FEEL YOU REQUIRE THIS SCAN. IF AFTER THE SCAN THE DENTIST FEELS YOU MAY BE AT High RISK, YOU MAY BE REFERRED TO A SPECIALIST (The cost of the scan is something you will incur independent of treatment costs)

I have been educated and informed regarding the following oral surgery procedure(s):

for which I am giving my consent and I understand the risks that are involved in performing this procedure. Specifically, I have been informed that:

1. there is a risk of temporary or permanent anaesthesia/paraesthesia to my lower lip(s). This means that my lip may remain numb even after the procedure. Attempts to correct this involve special additional procedures.
2. postoperative bleeding is a normal consequence of this procedure, however, there are occasional instances that a patient's blood does not clot normally. In this case, additional care by the dentist or a physician may be necessary.
3. some swelling may occur due to the trauma and this might resolt in bruising.
4. because of the trauma to a surgical site, this site may later become infected and require additional care. I agree to take the antibiotics prescribed to me in the manner I was informed so as to minimise this possibility. (Females) Antibiotics can interfere with birth control therapy.
5. bone fragments may later dislodge from the surgical site and need to be removed.
6. during procedures in the maxillary (upper) jaw, the maxillary sinus may perforate and require additional treatment to be repaired.
7. Adjacent teeth can be effected by oral surgery procedures. Adjacent teeth with decay can break. Weak crowns can pop off or break and teeth with large fillings can break. This may require additional treatment.
8. Additional potential complications described (if necessary ):

I have been educated and informed regarding the following oral surgery procedure(s):

for which I am giving my consent and I understand the risks that are involved in performing this procedure. Specifically, I have been informed that:

1. There is a risk of graft migration or rejection, which may require further bone grating in this area.
2. There may be symptoms of sinusitis (pain/pressure), these are usually transient.
3. During this procedure, the maxillary sinus may perforate and require additional treatment to be repaired.
4. Bleeding is a normal consequence of this procedure, however, there are occasional instances that a patient's blood does not clot normally. In this case, additional care by the dentist or a physician may be necessary. Bleeding from your nose is normal.
5. Swelling will occur due to the trauma and this might result in bruising.
6. There is a risk of Infection which will require additional care. Taking the antibiotics prescribed will minimise this possibility. (Females - Antibiotics can interfere with birth control therapy)
7. Adjacent teeth can be effected by oral surgery procedures. Adjacent teeth with decay can break. Weak crowns can pop off or break and teeth with large fillings can break. There may be a risk to the nerves of the adjacent teeth. This may require additional treatment.

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that my teeth are discolored and could be treated by a take-home whitening (also known as “bleaching”).

DESCRIPTION OF THE PROCEDURE

‘Home Kit’ whitening is a procedure designed to lighten the color of my teeth using a combination of a carbamide peroxide gel and a specially designed ‘mouth guard’. The treatment involves using the gel inside the trays overnight to produce maximum whitening results in the shortest possible time. During the procedure, I will apply the whitening gel trays and place these carefully in mouth to be worn for a minimum of 4(four) hours overnight. Before the treatment, the shade of my upper-front teeth will be assessed and recorded and I may wish to return after I have completed my treatment to have my new shade recorded. Before and after photos can be taken on request.

ALTERNATIVE TREATMENTS

I understand I may decide not to have the ‘Home Whitening’ treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:

• Whitening Toothpastes/Gels
• In-office Laser Whitening

RISKS OF CONSENT FOR TREATMENT

I also understand that ‘Home Kit’ whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from ‘Home Kit’ whitening treatments and significant whitening can be achieved in most cases.

I understand that ‘Home Kit’ whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth.

I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all.

I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives.

I understand that provisional or temporaries made from acrylics may become discolored after exposure to ‘Home Kit’ whitening treatment.

I understand that ‘Home Kit’ whitening treatment is not recommended for pregnant or lactating women.

I understand that the results of my ‘Home Kit’ whitening treatment cannot be guaranteed.

I understand that ‘Home Kit’ whitening treatments are considered generally safe by most dental

Professionals.

I understand that although my dentist has been trained in the proper use of the ‘Home Kit’ whitening system, and will pass that training on to me, 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/Pain – During the ‘Home Kit’ whitening treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following ‘Home Kit’ whitening subsides within 24 hours after the last session, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open 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 during and after ‘Home Kit’ whitening treatment.

Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or ultraviolet light.

Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will most likely have increased sensitivity. The will also not lighten to the same degree as the rest of the tooth.

Root Resorption – This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures.

Relapse – After the ‘Home Kit’ whitening, it is natural for the teeth that underwent the treatment to regress slightly 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 repeating the ‘Home Kit’ whitening.

Specific 2WW Information

Urgent 2WW Referral

This patient consent contains important information relating to your retainers and ending of your orthodontic treatment.

BY SIGNING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN.

I understand that my active orthodontic treatment has now been completed. My clinician and I are both satisfied with the current position of the teeth and are therefore ready to order the Vivera Retainers to enter the retention phase of treatment

Therefore, I am now in my retention phase.

Smile Rooms Kingston have provided me with retainers (permanent or removable OR both) and wear instructions have been explained to me.

What are retainers?

Retainers are designed to hold your teeth in their corrected positions after the braces have been taken off or you have completed your Orthodontic treatment. Orthodontic retainers are custom-made devices, that hold teeth in position after surgery or any method of realigning teeth. A set of 3 identical Vivera retainers should last 3-5 years according to Invisalign, the longevity governed by wear and care at home. After which, the financial responsibility is on me to replace these with Reading Smiles or a practice of my choosing to avoid my teeth moving position. At the end of treatment, my clinician and I will discuss if fixed retainers are suitable or recommended based on how my teeth responded to movement and treatment.

How often do I wear my retainers?

I understand that the retainers are to try and prevent any un wanted tooth movement (relapse) and I need to wear them full time for the first three months. Following this, the retainer must be worn for at least 12 hours per day (mostly whilst sleeping) our advice would be to continue to wear the retainers on a lifelong basis to maintain the teeth in the corrected position following the first year of retainer wear.

What if my retainers stop fitting or don’t fit initially

The first few days may be uncomfortable, however I must notify the practice within 14 days if they are not fitting, and Invisalign can be contacted to SWAP the retainers for another set. The old set must be returned in full to be given a replacement. It is your responsibility to notify the practice asap and arrange a rescan, failure to do so may cause a relapse and new treatment fees would apply.

Instructions for cleaning and wear:

Remove retainers for EATING, CONTACT SPORTS, BRUSHING TEETH and keep safe in storage case. Clean them inside and out with a brush and water, then rinse in cold water. DO NOT CLEAN RETAINERS WITH HOT WATER! It is useful to clean your retainer regularly using a cleansing agent which may be purchased from the chemist or your orthodontist such as ‘RETAINER BRITE'

IT IS YOUR RESPONSIBILITY TO KEEP YOUR TEETH IN THEIR CORRECTED POSITIONS. If the retainers are not worn then your teeth may move and will not be ideally aligned.

What is Invisalign?

Invisalign is a series of thin, clear plastic, removable appliances (aligners) that move your teeth in small increments from their original position to a more aligned position. After a dental exam and x rays, a series of custom aligners are prescribed and made to fit you and monitored throughout the course of wear by an orthodontic therapist and dentist. 

Benefits: Aligners offer an aesthetic alternative to conventional braces as they do not have the metal wires or brackets associated with conventional braces. Aligners are nearly invisible so many people won’t realise you are in treatment. No metal or wires usually means less time is spent at the dental practice having adjustments made. Tooth movement can be visualised through the Clincheck software. Aligners allow for normal brushing and flossing tasks that are generally impaired by conventional braces.

This patient agreement contains important information about your treatment. 

BY SIGNING THIS PATIENT AGREEMENT YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN.

I agree to:

• the procedure that has been proposed and explained to me by the dentist named on this form.
• the use of the appliance, attachment and Interproximal Reduction (if appropriate).

I understand:

• and have been fully informed of the nature of the treatment and of any likely complications of the treatment
• that this is a cosmetic procedure and maintenance of my own oral health is paramount and depends on my compliance with instructions given by the dentist
• that as it is a cosmetic procedure I understand the limitations of the treatment prescribed and other options have been made aware to me. 
• that any procedure, in addition to this treatment, will only be carried out if necessary in my best interests and can be justified for clinical reasons and will be explained before being carried out.

I have:

• told the dentist about any additional procedures I would not wish to be carried out without my having the opportunity to consider them first.
• informed the dentist about my existing medical conditions and infectious diseases that are known to me.
• informed the dentist about any medication I am taking or have taken in the recent past.

Note:

• If there is anything that you do not understand about the explanation, or if you want more information, please ask the dentist or the treatment coordinator.
• Please check that all the information on the form is correct. If it is, and you understand the explanation letter, then sign the form.  

Patient responsibilities

• To ensure you outline exactly what you want to change with regards to your smile. 

• To look after your oral health, follow the brushing and oral hygiene instructions that are given to you and aim for a hygiene visit with us or your regular hygienist every 3 months and continue with routine dental examinations every 6 months to be arranged by you to maintain your oral health.  

• To let the dentist know if you had any trauma to a tooth at any stage. For example, if you knocked a tooth when you were young it may be compromised. 

• Attendance – To attend all appointments at the correct day and time, with non-attendance without 48 hour’s prior notice charged incurring a cancellation charge. 

• Treatment time – This will be indicated by the clinician, however is also affected by external factors such as how much you comply with wear time, or if 1 or more teeth are particularly stubborn. This is not a guaranteed treatment duration. 

• Eating and Drinking – You cannot eat whilst wearing removable appliances as this can damage your teeth and aligners/retainers. 

• Replacing Aligners – Whilst we can do our best to rescan and replace your lost aligners in exceptional circumstances for no additional cost in the first instance, for further losses or retainers there is an additional charge in accordance with our usual treatment fee guide at the time of replacement. 

• Swapping to fixed braces – In the rare event you would like to swap to fixed braces, an additional fee of £1,200 would apply to do so. 

• Cancelling Treatment – By signing this consent, you understand that the aligners will be prescribed and ordered. From this point or at any point during treatment this becomes non-refundable even under extenuating circumstances. The clinician can not be held liable to your further costsor treatment risks if you choose to terminate treatment.  The cancellation fee for Invisalign is £1,500 after aligners are ordered. 

• Payments – Once you have chosen your referred payment method, if you are spreading the cost of treatment using direct debit, if any payments are missed for any reason these must be paid prior to your next appointment in order to dispense your next set of aligners. In an unforeseen event of dentist not being able to treat you due to some emergency or personal reason, we will make suitable arrangements for you to be seen by another practitioner.

• Other Treatment Fees - Please note that any additional dental treatment aside from Invisalign that becomes necessary during OR following your Invisalign treatment will be a separate cost. This includes composite or edge bonding, veneers, crowns or fillings. This can be carried out at this practice or any other of your choosing.

Retention

IMPORTANT: Retaining the position of your teeth after Invisalign or any orthodontic treatment will be a lifelong commitment. Forgetting to wear nightly, replace or care for your retainers will likely cause a relapse in the position of your teeth into an undesirable position.

You and your clinician will only order or fix your retainers when both parties are satisfied with the position of your teeth. If you are not yet satisfied, it is imperative you communicate this.

We include a set of 3 identical Invisalign Vivera retainers in your treatment. In total, these should last around 3-5 years depending on the care at home. After this, the financial responsibility will fall on you as the patient to ensure you retain the position of your teeth through 12 hours per day wear at home. Immediately after treatment, we usually recommend 3 months of full time wear.

Retainers are designed to hold your teeth in their corrected positions after the braces have been taken off or you have completed your Orthodontic treatment. Orthodontic retainers are custom-made devices, that hold teeth in position after surgery or any method of realigning teeth.

I understand I will need to wear retainers for as long as I would like to maintain the position of my teeth.

During Treatment – Comfort and Medical Risks

• Soreness & Discomfort: Some discomfort is expected, however due to the gentle but steady alignment forces generated, the appliances are easily tolerated. Paracetamol or ibuprofen may be taken to relieve this with your General Practitioner’s consent. If you feel more than normal pressure of discomfort, or the soreness prohibits eating even soft food, please call for an appointment so any necessary adjustments may be made.

• Speech: The invisible Aligner may temporarily affect speech and may or may not result in a lisp, you will however acclimate to the appliances over time and effected speech will improve.

• Mid-Course Correction: Even if the treatment goes broadly to plan, usually some refinement is needed at the end of treatment. A new scan may be taken for a new set of aligners. This is known as mid-course correction and can further lengthen the overall treatment time. Risks/Inconveniences unexpected problems and considerations

• Tooth decay, Decalcification, Periodontal Disease: Bacteria present in plaque release acids that draw calcium and phosphorous out of the outer surface of the teeth. Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush or floss their teeth properly before wearing the aligner. Patients undergoing treatment should minimise the amount and frequency of sugar in their diets. Hygiene Treatment is recommended and can be arranged. We recommend you having a 3 monthly hygiene appointments.

• Injury from Aligners: Aligners are designed to have minimal amount of injury potential and maximum amount of strength. Accidents, nevertheless, can occur. It is also possible for a patient to swallow or inhale parts of the appliance/s or attachments. The cheeks, lips and gums may be scratched or irritated by the position occasionally.

• A tooth may become ankylosed (tightly bound): occasionally, to its surrounding bone, this is not preventable or predictable. It may not be possible to move the tooth at all. A change in the plan of treatment may become necessary and the costs may differ.

• Jaw Joint: It is important that we are told about Temporary Mandibular joint/Jaw problems so that we can deal with them appropriately and promptly. There are some patients who will develop popping/clicking or other problems in their jaw joint during or after treatment. This is very rare. Please keep us informed if you have any concerns.

• Final Stability of teeth: The teeth and jaw structure are a system that is constantly changing throughout one’s life. Retainers that patients wear will enhance the stability of the final result and minimise changes but does not make a patient immune to this process. Maturity changes that occur after active alignment treatment may alter the quality of the end result. If a patient decides to stop wearing their retainers at any point, their teeth may change and some of the original problems may re-emerge which can only be corrected through alignment treatment and additional costs.

• Enamel wear: The tooth’s enamel surface is made up of a crystalline structure and like other crystals, it can have undetected fracture lines and defects within it. The enamel may also erode when a patient grinds their teeth to an excessive extent.

• Existing Dental Bridges: There is a chance, even with careful planning, that a bridge may be damaged by any Invisalign treatment. This can be discussed with your clinician but would be a separate cost that can be done with Reading Smiles or a practice of your choosing. 

Final Appearance and Further Treatment Risks

It is important to remember that this is tooth alignment, therefore it will not alter the size or shape of the tooth other than that done with IPR. 

Tooth sculpting – different to dental bonding: Tooth sculpting is including in your Invisalign package after your teeth have been aligned. As per the teeth below, any rough edges are smoothed or buffed out along the edge of the tooth. This does not involve ‘filling’ or ‘adding’ any material to the tooth as would be required with composite or edge bonding. 

Space Triangles: Invariably, there may be the appearance of space triangle (also known as black triangles) once teeth are straightened. This is due to the natural shape of the teeth being narrower towards the gum and wider at the bottom/top of the tooth. In most cases this is not too noticeable, if this bothers you, this can be corrected with composite bonding to a certain extent at an additional cost to you.

• Oral Surgery: Tooth removal or orthodontic surgery (jaw surgery) is sometimes necessary in conjunction with alignment treatment, especially to correct severe jaw misalignments/imbalance or crowding. These procedures will only be recommended if it improves the prospects for successful treatment.

• Allergic reaction to aligner coating: Allergic reactions to the invisalign clear retainers are rare but are still possible. A few signs to look out for are:

• Rash or skin irritations
• Shortness of breath

• If these do occur, please contact us immediately so we can assess the situation and give you the best advice tailored to your situation

• Loss of Vitality: Vitality loss can occur before, during or after the movement in teeth. A tooth that has been traumatised from a deep filling or even a minor blow can die over a long period of time with or without tooth alignment treatment and is therefore not able to be predicted. Ways to assess if teeth are dying is that it goes a grey/brown colour. This can be easily treated with a root canal treatment and a veneer (composite or porcelain) to mask the discoloration. In worse cases, the tooth will need to be removed and treatment will have to be terminated. This is all done at an additional cost to the patient with us or another practice. Similarly, if root canal treated teeth become symptomatic during treatment, re-root canal treatment may be required at additional cost to the patient and may cause treatment to be paused or terminated. Cancellation fees would still apply.

• Root Resorption: Usually this effect is mild and does not compromise the teeth. However, sometimes this root resorption can be extensive and may then endanger the teeth. It is recognised that some patients are prone to this happening and some are not. It is not possible to predict which teeth might be affected. The dentist may recommend to take regular progress x-rays of their patient’s teeth during the treatment process to evaluate whether root resorption is occurring. Treatment without this risk may not be possible.

• Use of Tobacco: It is proven that tobacco reduces the blood flow to the tissues of the mouth, at a time when, good blood flow is needed for tooth movement. We recommend that all tobacco users cease the practice of tobacco use and seek advice from their orthodontist/dentist or General Practitioner (GP)

• Oral Hygiene: Gum disease can occur if patients do not brush their teeth properly and thoroughly during treatment period. Having any form of brace automatically places you at a higher risk of getting gum disease or worsening of gum disease. Although this is much less prevalent with removable appliances like the Inman Aligner/Invisalign, excellent oral hygiene and plaque removal is a must. Sugars and between meal snacks should be reduced as much as possible. It is important that your mouth and gums are cared for to a high standard. We recommend a hygienist appointment before, during and after treatment to ensure you are aware of the oral care required for proper hygiene and are able to perform these easily for yourself. If there is any build-up of calculus/tartar you will be informed and advised to see the hygienist/dentist for a clean. Not removing this will risk your oral health and will stop your orthodontic treatment from working. If you do not have it removed or cleaned, we may have to stop orthodontic treatment /remove the brace. This will mean you lose out on the full value of the orthodontic treatment and effect the treatment time and results.

• Gum Recession / Gum Tissues: The bone-gum relationship around teeth is always dependent upon whether there is enough bone to support the gum tissue properly. Many times when very crowded teeth are straightened there is a lack of bone and supporting gum tissues surrounding the teeth. This can cause recession which may happen during or after orthodontic treatment. However it is found people tend to brush their teeth more often and vigorously than before when going through orthodontic treatment causing the gums recede at a faster rate. Any additional treatment with a periodontal specialist for this will be at additional costs to the patient.

Patient relocation from Smile Rooms Kingston

In the event you should move away from Smile Rooms Kingston or relocate outside the UK, the treatment process will naturally need to be amended. We are able to offer a Virtual Care service and post out aligners as and when needed. Although we will be unable to carry out essential reviews, IPR or additional scans and would recommend searching for a local provider to offer this service. This service will need to be funded separately and will not be included within your treatment package. If you wish to transfer to a local Invisalign prescriber a refund will not be offered as such fees have already been paid. If you choose to terminate treatment due to relocation the full treatment becomes non-refundable even under extenuating circumstances.