1. I understand that in preparing the teeth for the reception of cosmetic veneers, it may 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. If 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 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, I may need a root canal or a possible crown. 

3. I understand that Composite Veneers may chip, break, stain, or tear apart after any time following placement. Many factors may contribute to this happening such as: chewing of excessively hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; failure of the bond between the veneer and tooth; and other such conditions over which the dentist has no control. 

4 . I understand I have 3 months warranty on every repair that is done. After the third month, I will be responsible for any repairs or replacements of composite veneers. Prices may vary from time to time and the office has the right to change them without notice.

5. I understand. Since the veneers may be wider and/or longer than the natural teeth they are covering, a difference in speech may be evident. Many times the patient will adapt to the change and speech returns to normal very shortly after placement. The veneers may need to be adjusted in order to alleviate problems with speech. 

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 It impossible to have the shade and/or form 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 procedure is NOT reversible.) 

9. I understand that composite resin veneers are susceptible to staining just like natural teeth. I must come in every 3 months to do maintenance that will cover cleaning my gums and polishing my teeth. Composite Resin Veneers tend to stain more readily than porcelain. The veneers may need to be replaced if excessive staining, marginal leakage, or chipping occurs. Every attempt to avoid stain-inducing foods and drinks should be avoided.

10. I understand that an acrylic lab fabricated night guard may be indicated to help protect my veneers from damage due to nighttime clenching and grinding. 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 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 In case of any broken, stained, chipped veneer, Hollywood Perfect Smile will not be responsible for any additional fees such as flight tickets, accommodation, transportation, or any other than dental office procedure.