INFORMATIONAL INFORMED CONSENT FORMS
INCLUDING GENERAL CONSENT, HIPPA, ORAL SURGERY AND DENTAL EXTRACTIONS
I UNDERSTAND that ORAL SURGERY and/or DENTAL EXTRACTIONS include possible inherent risks such as, but not limited to the following:
Injury to the nerves of the lips, the tongue, the tissues in the floor of the mouth, and/or the cheeks, etc. These possible nerve injuries can cause numbness, tingling, burning, and loss of taste in the case of the tongue which may be of a temporary nature lasting a few days, a few weeks, a few months, or could possibly be permanent.
Bleeding, bruising, swelling: Bleeding may last several hours. Should it persist, particularly being severe in nature, it should receive attention and this office must be contacted. Bruising may possibly be prolonged.
Dry socket occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry sockets can be extremely painful. Smoking drinking liquids through a straw and not following postoperative recommendations can increase the chances of this complication.
Suture and fractured root tips: In some cases root tips fracture and are no longer accessible. Root tips are frequently seen on x-rays and are not a threat if watched until healing occurs. The decision to leave a root tip alone is the dentist’s responsibility but you will be informed of the decision. Sutures are often not indicated and in some cases do more harm than good. Whether to place a suture or not is a matter of professional judgment and even when sutures are present they often begin to dissolve or come loose within a short time. The body will naturally absorb them.
Sinus involvement: In some cases, the root tips of upper teeth lie in close apposition to the tissues of the sinuses. During extraction or surgical procedures, the thin bone and tissues surrounding the sinus may be perforated. Should this occur, it may be necessary to have the sinus surgically repaired.
Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile or infected oral environment, for infections to occur postoperatively. At times these may become serious. Should severe swelling occur, particularly accompanied with fever or malaise, attention as soon as possible should be received and this office must be contacted. In some cases hospitalization and/or treatment with I.V. antibiotics may become necessary.
Fractured jaw, roots, or bone fragments: There is a possibility, even though extreme care is exercised, that the jawbone, teeth roots, or bone spicules may be fractured or be fractured which may require referral to a specialist for treatment. A decision may be made to leave a small pieces of root or bone fragment in the jaw when its removal would require extensive surgery and/or risk of complications.
Injury to adjacent teeth, fillings or porcelain crowns may occur no matter how carefully surgical and/or extraction procedures are performed. Fractured fillings or crowns may require replacement.
Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, the tissues of the heart in some cases and due to a number of conditions may be susceptible to bacterial infection transmitted from the mouth to the heart through the circulatory system. A condition called bacterial endocarditis (an infection of the heart) may occur which can result in damage to heart valves. If any heart problems are known or suspected (such as a heart murmur following rheumatic fever, existence of an artificial heart valve, cardiac damage following PhenFen use, etc.), the dentist must be informed prior to surgery.
Muscle or jaw soreness may be noticed following oral surgery and especially third molar extractions. Pre-existing conditions affecting the jaw joints (TMJ) may be aggravated by oral surgery. Clicking, popping, muscle soreness and difficulty opening may be noticed for some time following surgery. If such symptoms or conditions persist, the patient should call our office. The patient must notify the dentist of any such pre-existing conditions prior to surgery.
Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. It is important to take all prescription drugs according to instructions. Women on oral contraceptives must be aware that antibiotics can render these contraceptives ineffective. Caution must be exercised to utilize other methods of conception during the treatment period.
It is my responsibility to contact the dentist and seek attention should any undue circumstances occur postoperatively and I shall diligently follow any preoperative and postoperative instructions given me.
INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and/or extraction of teeth and have received answers to my satisfaction. In the feeble Elderly, surgury may hasten or cause death. I have been given the option of seeking care from an oral and maxillofacial surgeon. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. James E. Russon and/or his/her associates to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications.
CROWNS AND FILLINGS INFORMATIONAL INFORMED CONSENT
Silver amalgam has been used for decades as a filling material for teeth and there are no proven scientific studies accepted by the American Dental Association which supports the belief by some opponents to the material that there is a possibility, although unproven, that silver amalgam may have an effect on the general health of a person due to its mercury content (50%). However, silver amalgam continues to be endorsed by the ADA as an acceptable filling material. However, there is no scientific evidence that having satisfactory silver fillings removed will consistently result in improved health. In pregnant and lactating women, it is an accepted precaution in numerous countries (also recommended by the State of Utah Department of Health) to refrain from using silver filling materials for new fillings due to concern about possible developmental effects of mercury content in the foetus. Disadvantages of silver fillings: (1) Fragility of Silver Amalgam: Silver amalgam is quite fragile until it has completely solidified. If is necessary to avoid chewing on recently placed amalgam fillings for approximately 24 hours. (2) Amalgam tattoos: Occasionally shavings generated by placement or carving of silver amalgam fillings may work their way into the surrounding gum tissues and become lodged. Over an extended period of time gray spots or tattoos may become visible within the mouth. (3) Over a period of time the tooth itself may assume a grey and darker appearance even in areas not immediately adjacent to the silver filling
Posterior composite resin fillings which are more aesthetic in appearance than some of the conventional materials which have been traditionally used to fill back teeth, such as silver amalgam or gold, may entail certain risks. There is also the possibility of failure to achieve the results which may be desired or expected.
Advantages of posterior composite resin fillings over silver fillings: Amalgam (silver) remains an acceptable restorative material. However, composite resin fillings offer two main advantages: (1) They are bonded to the components of the tooth which may add additional strength to the tooth structure; (2) They are tooth colored and thus allow for a more esthetic restoration.
Disadvantages of posterior composite resin fillings: (1) Posterior composite resin fillings take more time, skill and effort to complete than amalgam (silver) restorations. Therefore, it may be necessary for the dentist to charge a higher fee for placing them. (2) Inherent in the placement of composite resin fillings is the potential for bond failure or fracture which may result in leakage and potential for rapid development of decay.
Regardless of which material is utilized, the teeth treated may remain sensitive or even possibly quite painful both during and after completion of treatment. If the pain is severe or extreme sensitivity persists for an extended period of time, please call Dr. Russon.
Regardless of which material is utilized I agree to assume the risks which may occur even though care and diligence will be exercised by my treating dentist in rendering this treatment. These risks include possible unsuccessful results and/or failure.
Necessity for Root Canal Therapy: When any type of fillings are placed or replaced, the preparation of the teeth for fillings often necessitates the removal of tooth structure adequate to insure that the diseased or otherwise compromised tooh structure provides sound tooth structure for placement of the restoration. At times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal, which oftentimes is exhibited by extreme sensitivity or possible abscess, root canal treatment or extraction may be required.
Injury to the Nerves: In any type of dental work, 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 which could occur is usually temporary, but in rare instances could be permanent.
Aesthetics or Appearance: Aesthetics are not a consideration in the case of silver filling material. When composite materials are used, effort will be made to closely approximate the natural tooth color. However, due to the fact that there are many factors which affect the shades of teeth, it may not be possible to exactly match the tooth coloration. Also, over a period of time, the composite fillings, because of mouth fluids, different foods eaten, smoking, etc. may cause the shade to change. The dentist has no control over these factors.
Breakage, dislodgment or bond failure: Due to extreme chewing pressures or other traumatic forces, it is possible for fillings to be dislodged or fractured resulting in leakage and recurrent decay. The dentist has no control over these factors.
Longevity of fillings, crowns, and bridges: There are many variables that determine "how long" fillings, crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Because of this, no guarantees can be made or assumed to be made concerning how long fillings, crowns and/or bridgework will last. Because crowns and bridges are statistically more reliable over a longer period of time than fillings, in the case of access restricted patients, consideration will be given to choosing a crown or bridge more often than a repair or filling involving the interproximal areas.
New Technology and Health Issues: Restorative material technology continues to advance but some materials yield disappointing results over time and some fillings may have to be replaced by better, improved materials. Insurance Related Issues: Some insurance carriers pay for all fillings placed in back teeth based on their table of allowances for amalgam (silver) fillings. This means that the patient share of the fee for posterior composite resin fillings or other restorative materials such as porcelaine may be more than what normally would be expected for amalgam fillings. If a patient elects to have cosmetic restorative materials placed in lieu of silver fillings, the patient understands that insurance benefits may be less and the patient's portion of the fee may be relatively higher. The dentist is obligated to report the actual material used to the insurance carrier. If composite resin, porcelaine or other newer restoratives are placed, the billing statement will state accordingly.
CROWN AND BRIDGE PROSTHETICS INFORMATIONAL INFORMED CONSENT
I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGEWORK includes certain risks and possible unsuccessful results, including the possibility of failure. 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. Nevertheless, I agree to assume the risks, possible unsuccessful results and/or failure associated with, but not limited to the following:
Reduction of tooth structure: In order to replace decayed or otherwise traumatized 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 possible.
Injury: During the reduction of tooth structure or adjustments done to temporary restorations, it is possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut). In some cases, sutures or additional treatment may be required.
Local Anesthesia: In order to reduce tooth structure without causing undue pain during the procedure, it will be necessary to administer local anesthetic. Such administration may cause reactions or side effects which include, but are not limited to, bruising, hematoma, cardiac stimulation, temporary or, rarely permanent numbness of the tongue, lips, teeth, jaws and/or facial tissues, and muscle soreness.
Sensitivity of teeth: Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity, which can range from mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If sensitivity is persistent, this office should be notified immediately such that all possible causes of the sensitivity may be ascertained.
Crowned or bridge abutment teeth may require root canal treatment subsequently: Teeth after being crowned may develop a condition known as pulpitis or pulpal degeneration. Usually, this cannot be predetermined. 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, particularly if teeth remain appreciably sensitive for a long period of time following crowning. Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical surgery or even extraction may be necessary.
Breakage: Crowns and bridges may possibly chip or break. Many factors can contribute to this situation such as chewing excessively hard materials, changes in biting forces exerted, traumatic blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes, but crowns/bridges may not actually break until chewing soft foods, or for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.
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 indeterminable periods of time following placement of the crown or bridgework.
Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation. If satisfactory, this fact will be acknowledged by the patient's signature (or signature of legal guardian) on the back of this form where indicated.
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 preceding paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Because of this, no guarantees can be made or assumed to be made concerning how long crown and bridgework will last. Because crowns and bridges are statistically more reliable over a longer period of time than fillings, in the case of access restricted patients, consideration will be given to choosing a crown or bridge more often than a repair or filling involving the interproximal areas.
It is the 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 ultimate failure of the crown/bridge to fit properly and an additional fee may be assessed.
INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of crowns, bridges and fillings and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired and/or any results from the treatment to be rendered to me. The fee(s) for these services have been explained to me and I accept them as satisfactory. By signing this form, I am freely giving my consent to authorize Dr. James E. Russon DDS MPH and/or all associates involved in rendering any services he/she deems necessary or advisable to treatment of my dental conditions, including the administration and/or prescribing of any anesthetic agents and/or medications.
I understand that it is my responsibility to notify Dr. Russon should any undue or unexpected problems occur or if I experience any problems relating to the treatment rendered or the services performed.
Informed Consent:
1. I authorize James E Russon DDS MPH of James E Russon DDS PC and Mobile-Dentistry.Org along with associated professionals to perform upon the above named patient any and all procedures, including but not limited to: local anesthetic, cleaning, x-rays, and any and all procedures that in their judgment may be necessary or advisable for the above patient’s well being and safety. 2. I acknowledge that the nature of my condition and the essence of the proposed health care procedure, together with any alternative method of treatment or non-treatment, have been thoroughly explained to my satisfaction including the chance of substantial risk or harm. 3. I acknowledge that I had a fair opportunity to ask questions about the health care procedures, their alternatives, and or complications. 4. I acknowledge that my questions have been answered in a satisfactory manner, and that I understand the attendant risks involved and voluntarily assume them. 5. It has been explained to me, that during the course of such procedure(s) or operations(s), unforeseen conditions maybe revealed which necessitate either an extension of the aforementioned procedure(s), or modification of them. I authorize and do request that Dr. Russon and Associated Dental Professionals perform any such additional procedure(s), or modifications of them. 6. I have been advised of the following potential complications from oral surgery, extractions, root canal treatment, periodontal surgery and anesthesia and related procedures: Common complications including but not limited to: pain, infection swelling, bleeding, bruising, discoloration, uncommon complications including but not limited: temporary or permanent numbness and tingling of the lip, tongue, chin, gums, cheek and or/teeth; pain and numbness of veins with intravenous injections; injury to or stiffness of the neck and facial muscles; changes in occlusion and/or temporomandibular joint: possible injury to teeth restorations and tissues adjacent to the tooth being treated; referred pain to ear neck and head nausea, vomiting, allergic reaction, fractured bone delayed healing and “dry sockets,: opening into the sinus or nose during and/or following extractions and or surgery. 7 I acknowledge that I have provided complete and accurate health history and have informed Dr. Russon and affiliated Dental Professionals of all major medical and or/ pathological conditions or diseases (no matter how insignificant or small the problem may be and informed Dr. Russon and associates of all medications, prescriptions and over the counter drugs (including: aspirin, Tylenol, cold remedies, etc), and that I am now taking or have taken in the past month. I hereby accept the responsibility to update and correct my health history and medications chart at each and every visit with Dr. Russon and Associates. 8. I understand that Dentistry is not an exact science and that, therefore, a reputable doctor cannot guarantee any specific results. No Guarantee or assurance has been given by Dr. Russon or Associates of the expectations of results that may be achieved. 9. I recognize that Dr. Russon is extending dental services beyond the expected standard of availability for my convenience, comfort and/or physical requirements. I cannot sign away my right to legally pursue any perceived personal wrong but agree that only acts or omissions which are grossly negligent or are willful and wonton will be considered grounds for legal remedy.
“I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desire results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.” I accept and trust Dr. Russon as my dentist. I believe that the only considerations in Dr. Russon’s mind, other than to perform high quality dental services are my personal right to choose and the right to benefit from his best efforts in my behalf. He also works to ensure that I have informed decision-making and consent. , I believe that Dr. Russon will try to do his very best under possibly trying circumstances. I believe and accept that his treatment will represent his best judgment. I believe that this is the essence of the professional relationship and voluntarily enter into it. I specifically authorize the following as dictated by Dr. Russon’s professional judgement: Exam; Necessary x-rays; Cleaning of teeth, Extractions to treat pain and/or infection.
HIPPA POLICY: PLEASE REVIEW The FOLLOWING CAREFULLY.
This is your Health Information Privacy Notice Please read it carefully. This notice describes how we protect the personal health information we have about you which relates to your "Personal Health Information", and how we may use and disclose this information. Personal Health Information includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also describes your rights with respect to the Personal Health Information and how you can exercise those rights.
We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAAWe are required by law to: Maintain the privacy of your Personal Health Information; provide you this notice of our legal duties and privacy practices with respect to your Personal Health Information; and follow the terms of this notice. We protect your Personal Health Information from inappropriate use or disclosure. Our employees, are required to comply with our requirements that protect the confidentiality of Personal Health Information. They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our products or services.
We will not disclose your Personal Health Information to any other company for their use in marketing their products to you. However, as described below, we will use and disclose Personal Health Information about you for business purposes relating to your Dental Insurance coverage.The main reasons for which we may use and may disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you. The following describe these and other uses and disclosures, together with some examples.For Payment: We may use and disclose Personal Health Information to pay for benefits under your Dental Insurance coverage. For example, we may review Personal Health Information contained on claims to reimburse providers for services rendered. We may also disclose Personal Health Information to other insurance carriers to coordinate benefits with respect to a particular claim. Additionally, we may disclose Personal Health Information to a health plan or an administrator of an employee welfare benefit plan for various payment-related functions, such as eligibility determination, audit and review or to assist you with your inquiries or disputes.For Health Care Operations: We may also use and disclose Personal Health Information for our insurance operations. These purposes include evaluating a request for Dental Insurance products or services, administering those products or services, and processing transactions requested by you. We may also disclose Personal Health Information to Affiliates, and to business associates outside of the MetLife family of companies, if they need to receive Personal Health Information to provide a service to us and will agree to abide by specific HIPAA rules relating to the protection of Personal Health Information. Examples of business associates are: billing companies, data processing companies, or companies that provide general administrative services. Personal Health Information may be disclosed to reinsurers for underwriting, audit or claim review reasons. Personal Health Information may also be disclosed as part of a potential merger or acquisition involving our business in order to make an informed business decision regarding any such prospective transaction.Where Required by Law or for Public Health Activities: We disclose Personal Health Information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Personal Health Information to a governmental agency or regulator with health care oversight responsibilities. We may also release Personal Health Information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.To Avert a Serious Threat to Health or Safety: We may disclose Personal Health Information to avert a serious threat to someone’s health or safety. We may also disclose Personal Health Information to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations.For Health-Related Benefits or Services: We may use Personal Health Information to provide you with information about benefits available to you under your current coverage or policy and, in limited situations, about health-related products or services that may be of interest to you.For Law Enforcement or Specific Government Functions: We may disclose Personal Health Information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose Personal Health Information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
When Requested as Part of a Regulatory or Legal Proceeding: If you or your estate are involved in a lawsuit or a dispute, we may disclose Personal Health Information about you in response to a court or administrative order. We may also disclose Personal Health Information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested. We may disclose Personal Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.
Other Uses of Personal Health Information: Other uses and disclosures of Personal Health Information not covered by this notice and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative. If we are authorized to use or disclose Personal Health Information about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization. You should understand that we will not be able to take back any disclosures we have already made with authorization.
Your Rights Regarding Personal Health Information We Maintain About You
The following are your various rights as a consumer under HIPAA concerning your Personal Health Information. Should you have questions about a specific right, please write to us at the location listed in our discussion of that right.
Right to Inspect and Copy Your Personal Health Information: In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you.
Right to Amend Your Personal Health Information: If you believe that your Personal Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Personal Health Information while it is kept by or for us.. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend Personal Health Information that: is accurate and complete; was not created by us, unless the person or entity that created the Personal Health Information is no longer available to make the amendment; is not part of the Personal Health Information kept by or for us; or is not part of the Personal Health Information which you would be permitted to inspect and copy.
Right to a List of Disclosures: You have the right to request a list of the disclosures we have made of Personal Health Information about you. This list will not include disclosures made for treatment, payment, health care operations, for purposes of national security, made to law enforcement or to corrections personnel or made pursuant to your authorization or made directly to you.
Right to Request Restrictions: You have the right to request a restriction or limitation on Personal Health Information we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request.. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on Personal Health Information uses or disclosures that are legally required, or which are necessary to administer our business.
Right to Request Confidential Communications: You have the right to request that we communicate with you about Personal Health Information in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail.
Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
