Patient Form

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Dr. M’s Dental Care is committed to protecting your health information. We use your information for treatment, payment, and healthcare operations. We may share information with other healthcare providers involved in your treatment, with insurance companies for payment, and as required by law. We will not disclose your information without your written authorization for other purposes.

You have the right to request restrictions on how your information is used, to receive a copy of your health information, to request corrections, and to file a complaint if you believe your privacy rights have been violated.

We understand that sometimes schedules change and life gets busy. However, we require at least 24 hours advance notice for any cancellations or rescheduling of appointments.

Patients who miss appointments or cancel with less than 24 hours notice may be subject to a cancellation fee of PKR 50. This fee is not covered by insurance and must be paid before your next appointment.

Three or more missed appointments or late cancellations may result in discharge from the practice. We appreciate your understanding and cooperation as this policy allows us to serve all of our patients effectively.

I understand that the initial visit may require radiographs in order to complete the examination, diagnosis, and treatment plan.

I have been informed and understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs. I understand that and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic medication and drugs that may have been given in the office for my treatment.

I understand that during treatment, it may be necessary to change or add procedures because of conditions found while working on teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any or all changes and additions as necessary.

I understand that some dental procedures may affect the jaw joints or muscles, and that I may experience symptoms including pain, stiffness, and limited jaw movement. I will inform the dentist of any existing TMJ symptoms prior to treatment.

I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage, and tooth sensitivity is a common after-effect of a newly placed filling.

I understand removing teeth does not always remove all infection if present, and it may be necessary to have further treatment. I understand that risks involved in having teeth removed include pain, swelling, and spread of infection, dry socket, loss of feeling in my teeth, lips, tongue, and surrounding tissues (paresthesia) that can last for an indefinite period of time, or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily, and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize that the final opportunity to make changes in my new crowns, bridge or cap (including shape, fit, size, placement and color) will be done before cementation. It has been explained to me that, in very few cases, cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures.

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize that the final opportunity to make changes in my new denture (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost of this procedure is not included in the initial denture fee.

I realize there is no guarantee that root canal treatment will save my tooth and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

I understand that I have a serious condition causing gum inflammation and/or bone loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including non-surgical cleaning, gum surgery, and/or extractions. I understand the success of treatment depends in part on my efforts to brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products, and follow other recommendations.

I hereby authorize Dr. M’s Dental Care, or any of their assignees, to take photographs, slides, and videos of my teeth, jaws, and face. I understand that the photographs, slides, and videos will be used as a record of my care, and may be used for communication with other healthcare professionals, educational publications (dental journals), and education lectures. The content may also be used for advertising purposes (including website publication, Facebook posts, Instagram, etc.).

I further understand that if the photographs, slides, and videos are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs. If I wish to revoke this consent, I may do so in writing.

I confirm that I have selected the above treatment(s) and understand the procedure, risks, and alternatives explained to me.