Preferred Name

Health History

Check all that apply:

NoneArtificial Heart ValveArtificial JointsBleeding GumsBlood ThinnersCancerChemotherapyChewing TobaccoCigarette, Pipe, or Cigar SmokingCongenital Heart DiseaseDiabetesDry MouthEpilepsyGrinding TeethHeart DiseaseHeart MurmurHerpesHIV/AIDSMental DisorderMitral Valve ProlapseNervous DisorderPacemakerRadiation TreatmentRheumatic FeverScarlet FeverTuberculosisOtherHepatitis

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Explain

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Have you been told by your physician that you need to be pre-medicated with an antibiotic prior to dental visits?

YesNo
Women: Pregnant?

YesNo
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If yes, Due Date:

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Women: Nursing?

YesNo

Allergies

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NoneAspirinCodeineEpinephrineErythroLatexPenicillinSulfaOther
Other Allergies

Current Medications

Are you currently taking any medications?

YesNo

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Medication

Reason

Prescribing Doctor

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Patient Agreement

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I authorize the release of my health information and treatment descriptions to my insurance carrier (if any) to secure the payment of benefits in connection with my dental claims.
I agree to pay the fees charged for dental services at the time services are rendered. If I have insurance, my portion will be estimated. This is just an estimate, my insurance company will decide on actual coverage. I understand that I am personally responsible for my account regardless of whether my insurance company makes a full, partial or no payment on the account.
I understand that a service charge of 2.5% per month will be added monthly on any unpaid balance over 30 days. Should my account be turned over for collections, I agree to pay all costs to collect the debt, including, but not limited to, interest, attorney's fees, court costs, and collection fees in the amount of 40%. The obligation to pay the collection fees shall be imposed at the time of assignment of the debt to a third party debt collection agency. Furthermore, I authorize the release of all financially identifiable information concerning my account to the collection agency or attorney.
Broken appointments inconvenience many people. If I am unable to keep my appointment, a 24 hour notification is appreciated so that my appointment time can be given to someone else. I understand that appointments not cancelled or re-scheduled at least 24 hours in advance MAY be subject to a fee.
I agree to receive electronic messages for appointment reminders. These messages may also be related to my healthcare, billing or other services provided to patients. I understand that I can update my text preferences at any time.
Responsible Party's Name *

Signature *
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Relationship to Patient *

Informed Consent Form

Dr. Schvaneveldt would like all of his patients to have knowledge of risks and benefits of dental procedures. No dental treatment is free of risk, but Dr. Schvaneveldt will take reasonable steps to limit any complications of your treatment. We ask that you review the procedures listed and feel free to ask any questions.

1. Drugs and Medication: Antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction.)

2. Changes in Treatment: During treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures.

3. Risks of Local Anesthetic: 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 anesthetics. The resulting numbness that can occur is usually temporary but, in rare instances, could be permanent.

4. Removal of Teeth: Alternatives will be explained to you (root canal therapy, crowns, implants, and periodontal surgery, etc.) The removal of teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. Some of the risks are pain, swelling, spread of infection, dry socket, loss of feeling in teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time (days or months), sinus perforation, or fractured jaw. Further treatment by a specialist or even hospitalization if complications arise during or following treatment would be your responsibility.

5. Crown, and Bridges: Sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. You may wear temporary crowns, which may come off easily. You will need to be careful to ensure that they are kept on until the permanent crowns are delivered. The final opportunity to make changes to a new crown, or bridge (including shape, fit, size, or color) must be done at the preparation appointment.

6. Partials: They are artificial, constructed of plastic, metal and/or porcelain. The problem of wearing these appliances, including looseness, soreness, and possible breakage. Most partials require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial fee.

7. Endodontic Treatment (Root Canal): There is no guarantee that root canal treatment will save a tooth. Complications can occur from the treatment and occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. Occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

8. Periodontal Loss (Tissue & Bone): This is a serious condition, causing gum and bone infection or loss and can lead to the loss of teeth. Alternative treatment will be explained to you (gum surgery, replacements, and/or extractions). Any dental procedure may have a future adverse effect on your periodontal condition.

9. Implants: They are a permanent alternative to bridges, partials or dentures. This process may involve the participation of an oral surgeon. Fees for his/her services are separate from our service fees. This process involves several steps and could last from 2-6 months before complete (depending on healing time needed). As with crowns, color may not match perfectly with natural teeth.

10. Sealants: There is no guarantee that a sealant will prevent all cavities. They do, however, form a hard shield that keeps food and bacteria from getting into tiny grooves and causing decay along the chewing surfaces of the back teeth. Occasionally sealants need to be replaced, since they do not last a lifetime. Sealants can be done at any age as long as the teeth are free of decay and fillings. The doctor will determine the best time to have them done.

11. Treatment risk: I understand that any time a restoration is performed there is a possibility of trauma to the nerve of the tooth, which could result in varying degrees of sensitivity and complications including, but not limited to the following: cold sensitivity, hot sensitivity, biting sensitivity, abscess, pulp necrosis.

Most of the symptoms usually resolve as the nerve heals. Complications may arise resulting in the need for additional treatment. This may include one or more of the following: bite adjustments, replacement of the restoration due to open margins discovered after final cementation, root canal treatment or tooth removal.

Your treatment plan, along with alternatives, will be discussed with you. Any costs discussed with you are estimates.

I have read the above informed consent and fully understand all risks, and have had any questions answered.

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