Dental Center General Dentistry

DENTAL CENTER Family Dentistry Mario J. Castellanos, D.D.S. GENERAL DENTISTRY INFORMED CONSENT All patients complete 1 thru 4 below, and 5 thru 10 as needed

1. EXAMINATION AND X-RAYS I understand that the initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan. The undersigned hereby authorizes the Doctor to take x-ray study models, photographs of mouth or teeth, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient’s dental needs. (Initials)______2. DRUGS MEDICATIONS AND SEDATIONS I have been informed and understand that the 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) they may cause drowsiness and lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of anesthetic, medication and drugs that may have been given to me in the office for my care. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection and pain and potential resistance to effective treatment of my condition. I understand that the antibiotics can reduce the effectiveness of oral contraceptives. (Initials)______3. TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD) I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near to the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with dental treatment are usually transitory in nature and well tolerated by most patients, I understand that should the need treatment arise, then will be referred to a specialist for and the cost of which is my responsibility. (Initials)______4. CHANGES IN THE TREATMENT I understand that during treatment it may by 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. I give my permission to the Dentist to make any/all changes and additions as necessary. (Initials)______5. FILLINGS I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage. I understand that sensitivity is a common effect after a newly placed filling. (Initials)______6. REMOVAL OR EXTRACTION OF TEETH Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.) and I authorize the Dentist to remove the Following teeth ______and any other necessary for reasons in paragraph # 4. I understand removing teeth does not always remove all The infection, if present and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are; Pain, swelling, spread of infection, dry socket, fractured jaw, and loss of feeling in my teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time. 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. (Initials)______7. CROWNS, BRIDGES, CAPS, VEENERS AND BONDING. I understand that sometimes it is not possible to match the color of natural 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 crown is delivered. I realize that the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size and color) will be 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 can not always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures. (Initials)______8. DENTURE COMPLETE OR PARTIAL I realize that full or partial dentures are artificial, constructed of acrylic, metal and or porcelain. The problems of wearing those appliances have been explained to me including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new denture (including shape, fit, size, placement, and color) will be during the teeth in wax try in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. (Initials)______9. ENDODONTICS TREATMENT (ROOT CANAL) I realize there is no guarantee that a root canal treatment will save my tooth and that complications can occur from the treatment, which include but are not limited to: metal objects that can be broken during the procedure, 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 (apicectomy). (Initials)______10. PERIODONTAL TREATMENT I understand that I have serious condition causing gum inflammation and/or bone loss, and it can lead to the lost 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 any treatment depends in part on my effort to brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products and follow other recommendations. (Initials)______I understand that dentistry is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I understand that each Dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist other than the treating Dentist or Mario J. Castellanos D.D.S. is responsible for my dental treatment. I acknowledge the receipt of and understand postoperative instructions and have been given an appointment date to return.

Signature______Date:______

Doctor______Witness:______DENTAL CENTER Family Dentistry Mario J. Castellanos D.D.S. DENTAL SERVICES AGREEMENT

______(Doctor) and the undersigned patient have agreed as follows:

ARTICLE 1. IT IS UNDERSTOOD THAT ANY DISPUTE AS TO DENTAL MALPRACTICE. THAT IS AS TO WHETHER ANY DENTAL SERVICES RENDERED UNDER THIS CONTRACT WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED,WILL BE DETERMINED BY SUBMISSION TO ARBITRATION AS PROVIDED BY CALIFORNIA LAW AND NOT BY A LAW SUIT OR RESORT TO COURT PROCESS EXCEPT AS CALIFORNIA LAW PROVIDES PER JUDICIAL REVIEW OF ARBITRATION PROCEDING, BOTH PARTIES TO THIS CONTTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF ARBITRATION.

ARTICLE 2. In the event of any claim, controversy or dispute the essential nature of which involves personal injury, malpractice or any sort, by patient, his dependents, whether or not minors, theirs al law or personal representatives against Doctor or any Doctor’s officers, directors, shareholders, agents, representatives, employer, successors in interests, assigns or associates agreeing in writing to be bound by the arbitration provision of this agreement (Affiliates),THE SOLE METHOD PER RESOLVING SUCH DISPUTE SHALL BE BY BINDING ARBITARATION ADMINISTRATED BY THE AMERICAN ARBITRATION ASSOCIATION in accordance with Commercial Arbitration Rules of the American Arbitration Association. The parties here by agree that they shall submit their controversy to an Arbitrator, each party shall pick an Arbitrator who is a Dentist licensed in California and the two Arbitrators shall pick a third Dentist proceeding under the rules of the American Arbitrators Association. Notwithstanding the foregoing, two additional Arbitrators who are Dentist may be added by the parties by agreement in writing to create an arbitration panel of three. It is agreed that all parties relevant to a full and complete settlement of any dispute subject to this agreement may be intervened or joined.

ARTICLE 3. The prevailing party in any arbitration pursuant to this agreement shall be awarded all cost, including reasonable attorney’s fees and the Arbitrator’s fees, in prosecuting or defending that claim in arbitration, but not to exceed $5,000 in amount. Furthermore, if any action is under taken to set aside or otherwise attack the binding arbitration award, the losing party in the court shall bear all prevailing party’s costs, including reasonable attorney’s fee.

ARTICLE 4. Any party initiating arbitration under this agreement shall file with his petition a bond or cash surety in an amount equal to $500 which shall provide security attorney’s fees and cost in the event that the moving party shall not prevail.

ARTICLE 5. This agreement shall govern all future services rendered to Patient by Doctor and Doctor’s Affiliates and Associates. Execution of this agreement is a precondition to the furnishing of services by Doctor, but this agreement may be rescinded by written notice by either party within thirty days of signature. After those thirty days, this agreement may be changed or revoked only by a written revocation signed by both parties.

ARTICLE 6. I understand that each Dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist or other treating Dentist nor Mario Castellanos D.D.S. is responsible for my dental treatment.

ARTICLE 7. Doctor here by agrees to render dental care and service to patient. Patient agrees to pay Doctor promptly upon the rendering of a bill at the current prevailing rates, or to cooperate with Doctor in obtaining payment from third party payers.

ARTICLE 8. Except for the fact that Doctor has indicated professional services will not be rendered to patient unless this agreement is executed, Doctor has made no other representations oral or written to induce patient to execute this agreement.

ARTICLE 9. In the event that any provision of this agreement shall be void or unenforceable for any reason what so ever then such provision shall be stricken and of no force and effect. The remaining provisions of this agreement, however, shall continue in full force and effect, and to the extent required, shall be modified to preserve their validity. This agreement shall be governed by California law.

THIS IS A BINDING LEGAL DOCUMENT WHICH MAY HAVE AN IMPORTANT EFFECT ON YOUR LEGAL RIGHTS, CONSULT YOUR ATTORNEY ON ANY QUESTION YOU MAY HAVE.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL SEE DENTAL SERVICES AGREEMENT OR COURT TRIAL. SEE ARTICLE #1 OF THIS CONTRACT.

I have received a copy of the Dental Material Fact Sheet as required by law. (Initials)______

______Patient or Parent Signature Date Relationship to Patient

______Doctor Date