Patient Forms

Informed Consent for Porcelain Veneers

Please read and sign this consent form covering the porcelain veneer procedure, expected outcomes and aftercare.

1. I understand that in preparing the teeth for the reception of porcelain veneers, it will be 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. The veneer covering breaks or comes off, the uncovered tooth may become susceptible to decay if the veneer is not replaced in a timely manner.2. I understand that through the process of modifying teeth to accept veneers, there is the possibility of the development of tooth sensitivity which may last for days or months following tooth preparation. In most cases, this sensitivity will alleviate over time but in rare instances, is permanent. If a longer period of sensitivity does acquire I may need a possible root canal to sustain a healthy tooth.3. I understand that though Porcelain Veneers are made to last a long time, they may chip, break, stain, or tear following placement. Many factors may contribute to this happening such as: chewing of excessively hard materials4. I understand that I have a 5-year warranty on every repair that is done as long as I come in at least once a year for my maintenance, for which I will have to cover the cost. After 5 years, I will be responsible to pay for every repair (in which the office has the right to change prices as seen fit).5. I understand that since the veneer.6. I understand that there may be sensitive or allergic reactions to anesthetics or materials used In the procedure.7. I understand that every attempt possible will be made to match and coordinate both the form and shade of veneers, which will be placed to be cosmetically pleasing to the patient. However, there are some differences, which may exist between that which is natural and that which Is artificial making impossible to have the same shade and/or form to perfectly match your natural dentition. Once veneers are bonded to place on the teeth, should the patient desire any changes later a fee may be assessed to cover any extensive adjustments or remakes.8. I understand it is impossible to place any specific time criteria on the length of time that veneers should last. . Once the tooth structure is prepared for veneer placement, the patient is committed to veneers for life. Should the veneers become damaged, leaky, or stained, they will need to be replaced (This process Is NOT reversible.)9. I understand that Porcelain Veneers are susceptible to staining over time just like natural teeth. I must come at least once a year, or preferably every 3 months, to do maintenance that will cover cleaning my gums and polishing my teeth. Every attempt to avoid stain-inducing foods and drinks should be avoided.10. I understand that a protective night Splint/Guard is essential and is recommended to protect the work done to help protect my veneers from damage due to nighttime clenching and grinding as well as Sleep Apnea (stress or sleep-related) which the Dr has no control over. I certify that I have read the above and fully understand this consent for treatment. I understand that a perfect result cannot be guaranteed. I am aware of the fee(s) associated with this treatment and I am responsible for any and all payments not covered by my insurance.11. I understand that Drs and/or one of its associates, has explained the composite resin veneers will not change my bite.12. I understand that proper brushing and flossing, a healthy diet, and regular professional cleanings are essential to help prevent decay (cavities) and gum irritation.13. I understand that periodontal (gum) disease can occur at any age, with or without crowns, fixed bridges or implants, and Veneers.14. I understand that the need for a root canal filling may not become apparent until after the restoration has been placed or during treatment. A root canal filling replaces the dental pulp, the innermost part of the tooth.15. I understand Provlslonal/Temporary Restorations are used to protect the teeth and provide a satisfactory appearance while the new restorations are being fabricated. They are not as strong as the final porcelain/metal restorations and are attached to the teeth with a relatively weak cement to Facilitate their removal at subsequent appointments. Therefore, It is important to minimize the chewing pressure on provisional restorations since they can be easily fractured and dislodged. For Implant crowns, a clear retainer is usually made that fits over the teeth, although temporary dentures can be made but are more expensive.16. I understand that Crown/Bridges/Veneers aid In its prevention, as does good oral hygiene, regular cleaning and dental examinations, a healthy diet, and good general checkup, Prior to treatment, the health of the gums must be controlled to prevent unwanted bone and gum loss, as well as maintain a healthy working environment during treatment.17. I understand that in case of any broken, stained, chipped veneer, Hollywood perfect Smile will not be responsible for any flight fees, accommodation, or transportation fees.

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6730 Taft St, Hollywood, FL 33024 · (954) 987-3309

(954) 987-3309

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Informed Consent for Porcelain Veneers