1263 Pleasant Grove Blvd., Suite 150 Roseville, CA 95747 phn #: … · 2019. 4. 29. · To our patients: although oral surgeons primarily treat the area in and around your mouth,

❏ Mr. ❏ Mrs. ❏ Ms. ❏ Dr. First Name M.I. Last Name

Sex: ❏ Male ❏ Female Birth Date Age Soc. Sec. # E-mail

Street Apt. City State Zip

Home Tel.( ) Cell.( ) Have you ever been a patient of our practice? ❏ Yes ❏ No

Referred By Has a family member ever been a patient of our practice? ❏ Yes ❏ No

Dentist Orthodontist Medical Dr.

Nearest relative not living with you Tel.( )

Employer Bus. Tel.( ) Ext.

In case of emergency, please contact Tel. ( ) Relation

Today’s DatePaTienT informaTion:

SeconDary DenTal inSurance comPany: SeconDary meDical inSurance comPany:

FIRST NAME LAST NAME



Name Relation S.S.# Birth Date

Street Apt. City State Zip

Tel. ( ) Employer Bus. Tel.( )

SPouSe or oTher guaranTor informaTion: ( if different from above)


Student: . . . . . . ❏ Full Time ❏ Part Time ❏ Not . . . . . . . . . . . . School Name and Address

inSurance informaTion:

SCHOOL NAME ADDRESS

CITY STATE ZIP

Primary meDical inSurance comPany:

FIRST NAME LAST NAME FIRST NAME LAST NAME

1263 Pleasant Grove Blvd., Suite 150 Roseville, CA 95747phn #: (916) 243 - 6360

Primary DenTal inSurance comPany:

Insured Name

Relationship DOB Sex: ❏ M ❏ F

Mailing Address

City State Zip

Social Security #

Home Tel. ( ) Cell. ( )

Custody / Court Order in Place? ❏ Yes ❏ No

Employer

Group Name

Insurance Company

ID # ❏ PPO ❏ HMO

Insured Name


Mailing Address

City State Zip

Social Security #



Employer

Group Name

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Insured Name


Mailing Address

City State Zip

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Employer

Group Name

Insurance Company


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Employer

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FIRST NAME

FIRST NAMEFIRST NAME

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To our patients: although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today’s office visit?yes no

1. Height Weight Are you in good health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ ❏

2. Have there been any changes in your general health in the past year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ ❏

3. Are you under the care of a physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of last visit ❏ ❏

If so, for what are you being treated?

4. Have you had any illness, operation or been hospitalized in the past five years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ ❏

If so, describe

5. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth? . . . . . . . . . . ❏ ❏

If so, describe where

6. Do you have a prosthetic joint / implant / heart valve replacement? . . . . . If so, describe where ❏ ❏

7. ❏ ❏

8.

Have you ever had general anesthesia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

❏ ❏Have you, or a family member, had any unusual or serious reactions to general anesthesia? . . . . . . . . . . . . . . . . . . . . . . .

yes no67. Is there a possibility of pregnancy? . . . . . . . . . . . . ❏ ❏68. Expected delivery date?

yes no69. Are you nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ ❏70. Are you taking birth control pills? . . . . . . . . . . . . . . ❏ ❏

note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Have you Had, or do you currently Have: yes no

38. Slow healing?

39. Tumor or growth?

40. Cancer / Radiation / Chemo?

41. Eye disease / glaucoma?

42. Mental health problems / anxiety / depression?

43. Developmental Delay?

44. Removable dental appliance?

45. Pain or clicking of jaws?

46. Contagious Disease?

47. Any other condition / problem not listed?

48.

Do you smoke?49.

# packs / day50.

Do you use alcohol?51.

Illicit Drugs?52.

53.

Have you Had, or do you currently Have: yes no

11. Asthma

12. Difficulty breathing?

13. Other lung problems / cough?

14. A Pacemaker / Heart valve replaced?

15. Heart problems?

16. Chest pain?

17. Irregular heart beat?

18. Heart surgery?

19. Stroke?

20. Trouble climbing two flights of stairs?

21. High or Low Blood Pressure?

22. Sleep Apnea / Use CPAP?

23. Bleeding Disorder?

24. Bruise / Bleed easily?

25. Hepatitis / Liver Disease?

26. Faint easily?

27. Seizures?

28. Thyroid Trouble?

29. Diabetes?

30. Kidney problems?

31. Dialysis?

32. High Cholesterol?

33. Arthritis?

34. Osteoporosis?

35. Prosthetic joint?

36. Stomach ulcers / Reflux?

37. Immune system problems?

healTh hiSTory:

Women only: (questions 67–70)

Other condition:

How much?

are you noW Taking: yes no

71. Any kind of medication, drug, pills?

72. Blood thinners (Coumadin, Plavix,Aspirin, Vitamin E, Ginko biloba,Aggrenox, Pradaxa, Fish oil)?

73. Have you ever taken diet pills?

74. Any natural product, herbalsupplement or homeopathic remedy?

75. Are you taking, or have you ever taken,bone density meds. or bisphosphonatessuch as Fosamax, Boniva, Actonel,IV– Zometa, Aredia, Xgeva, Prolia, orReclast in the past 12 years?

76. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on aregular basis? If so, please list:

77. Please list any medications you are currently taking. Use the backif necessary. Or, if you have a list, please give it to us & we will make acopy.

Medication Dosage Frequency

are you allergic to, or Had a reaction to: yes no

78. Local anesthetic (numbing meds.)?

79. Penicillin?

80. Other antibiotics?

81. Sulfa drugs?

82. Sodium pentothal / Valium /other tranquilizers?

83. Aspirin?

84. Amoxicillin?

85. Codeine or other narcotics?

86. Other medications?

87. Latex?

88. Soy?

89. Eggs / yolk?

90. Sulfites?

91. Do you have any known allergies?

92. Please list any allergies other than drug allergies:

If you are having surgery today, have you had anything to eat or drink

in the last 8 (eight) hours? ❏ Yes ❏ No

Who is driving you home?

Is there any condition concerning your health that the Doctor should

be told about? ❏ Yes ❏ No – If Yes, describe:

Is there a family history of:

❏ Cancer ❏ Diabetes ❏ Heart disease ❏ Anesthesia problems

i certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my

satisfaction. I will not hold my doctor, or any other member of his staff, responsible for any errors or omissions that I have made in the completion of this form.

X XSignature of patient (Parent or Guardian if Minor) Date

FINANCIAL RESPONSIBILITY STATMENTI, the undersigned certify that I am financially responsible for all charges whether or not paid by insurance. I assign directly to Dental Designs of Roseville all insurance benefits,if any, otherwise payable to me for services rendered. I hereby authorize Dental Designs of Roseville to releasae all information necessary to secure the payment of benefits and I authorize the use of this signature on all insurance submissions. I understand that 60 days after the service date my balance due will accrue finance charges of 1.5% per month.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. it is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.


This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

X XSignature of patient: (Parent or Guardian if Minor) Date

auThorizaTionI authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any infor-mation acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment.

X Signature of patient (Parent or Guardian if Minor)

i hereby acknowledge that a copy of this office’s notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.


HIPPA

Pursuant to the information contained in the Notice of Privacy Practices, I give permission for the use and disclosure of Protected Health Information (PHI) in order to carry out Treatment, Payment, and Healthcare Operations (TPO).

I am aware that I have the right to review the Notice of Privacy Practices prior to signing this consent. Should the Notice of Privacy Practices be revised, I am aware that I may obtain a copy of the revised form by contacting the Medical Director of this facility.

I hereby consent to the use and disclosure of my PHI for the purpose of Treatment, Payment, and Healthcare Operations (TPO). This consent is good until revoked in writing, except to the extent disclosures have been made in reliance upon my prior consent.

I hereby consent that photographs may be taken during my treatment to be used in a manner for medical programs developed on behalf of Dental Designs of Roseville. I give my permission for these photographs to be used for educational purposes. I understand that my name will not be published on any of these materials beyond the documentation for my chart.

Services are provided without regard to sex, race, color, religion, national origin, or disability. Initial _____

I give my permission to release information regarding my appointments or account information to _________________________________.

In the event of an EMERGENCY please contact: _____________________ Name of Emergency Contact

____________________________ ___________________________ Relationship of Person Phone Number

Patient Name: _________________________________ Date: ____________

Patient Signature or Legal guardian: ________________________________________

Dental Appointment Cancellation Agreement

In order to maintain an efficient and effective dental facility, we need to ensure that our patients will arrive to their scheduled appointments. We request a courtesy of 48 business hours for any change or cancellation of your appointment. This allows us the time we reserve for you in our schedule to be filled by another patient who may have been waiting for this appointment time. We do, however understand that illness and emergencies may occur and we do make exceptions for those rare occasions.

A fee will be charged to your account for not honoring this agreement. For and appointment scheduled with our Hygienists’ or Doctor the fee will be $50.00 an hour of your scheduled appointment time. A cancellation of Oral/IV sedation less than 72 hours before a scheduled appointment time will include a nonrefundable deposit of $500.00

We reserve the time in our schedule in advance in order to accommodate your busy schedule. We ask that you give us the same consideration when needing to change or cancel your appointment.

_____________________________________________________________________________________ Patients Signature or Legal guardian Date

_____________________________________________________________________________________ Patients Name (Printed)

*Patient Name ___________________________ _________ ____________________________ First Mid Initial Last

Arbitration Agreement

ARTICLE 1

It is understood that all disputes, including but not limited to alleged medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, or any disputes arising out of Patient's relationship with Doctor will be determined by submission to arbitration as provided by California state law and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

ARTICLE 2

a. Parties To The Agreement The term "Patient" as used in this Agreement includes theundersigned individual, his or her spouse, children (whether born or unborn), andheirs, assigns, personal representatives, or executor of Patient's estate. The individualsigning this Agreement signs it on behalf of the foregoing persons, and intends to bindeach of them to arbitration to the full extend permitted by law.The term "Doctor" as used in this Agreement includes the undersigned doctor and his professional corporation or partnership, and any employees, agents, successors-in-interest, heirs and assigns of the foregoing individuals or entities. The Doctor signing this Agreement signs it on behalf of all the foregoing individuals and entities, and intends to bind each of them to arbitration to the full extend permitted by law.

b. Treatment Covered Patient understands and agrees that any dispute of the sortdescribed in Article 1 between Doctor and Patient will be subject to compulsory, bindingarbitration.

c. Other Doctors (If Applicable) Patient understand that he or she may at times receivetreatment form one or more doctors who practice jointly with the undersigned Doctor.It is understood and agreed that any dispute of the sort described in Article 1 betweenPatient and such doctors practicing with the undersigned Doctor will be subject tocompulsory, binding arbitration.

d. Coverage of Prenatal Claims (If Applicable) Patient understands and agrees that, ifDoctor treats her during pregnancy, and dispute of the sort described in Article 1 as tomedical treatment rendered to or affecting the unborn child will be subject tocompulsory, binding arbitration.

ARTICLE 3

a. Informal Resolution of Disputes In the event Patient feels that a problem has arisen inconnection with the medical care rendered by Doctor to Patient, Patient will promptlynotify Doctor so that Doctor may have the opportunity to resolve the matter. Notice maybe given orally or in writing, and shall stop the running of the statute of limitations for90 days.

b. Method of Initiating Arbitration If the dispute is not resolved by mutual agreementwithin 90 days of the notice required under Article 3, Subsection(a) of thisAgreement, Patient may initiate arbitration by notifying Doctor to the effect and bydesignating an arbitrator to act on Patient's behalf. Within 20 days of receipt of suchnotice, Doctor will designate an arbitrator to act on Doctor's behalf. In the event thatmore than two parties participate, parties aligned Doctor shall select a second arbitrator.The two "party" arbitrators shall select a neutral arbitrator. The controversy shall then besubmitted to the three arbitrators for a final and binding decision. Each party shall payon-half of the costs and expenses of the arbitration, and each shall separately pay itsrespective counsel fees, witness fees, and expenses.

c. Applicable Law The arbitration shall be conducted pursuant to California's UniformArbitration Act IRCW 6.04A.010-903). Pursuant to RCW 7.04a.170, the arbitrators shallhave authority to order such other discovery as they deem appropriate for a full and fairhearing of the case. A determination on the merits shall be rendered in accordance withthe law and rules of the State of California.

d. Interpretation of Agreement Any controversy concerning the interpretation orapplication of this Agreement itself shall also be submitted to arbitration in the mannerprovided above.

ARTICLE 4

Revocation If you sign this Agreement and then change your mind, the law permits you to revoke the Agreement, providing you give the undersigned Doctor written notice within 30 days from signing that you want to withdraw from the Agreement. However, Doctor and Patient agree that any claim arising from medical services rendered prior to revocation shall be subject to arbitration in accordance with this Agreement.

If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

⃝ I agree to have any and all disputes including, but not limited to, issues of medical malpractice decided by neutral arbitration and I give up my right to a jury or court trail. (See Article 1 of this contract).

Signature ____________________________________ Date: ____________________________ Patient, Parent/Guardian

Dental Materials – Advantages & Disadvantages

PORCELAIN FUSED TO METAL This type of porcelain is a glass-like material that is “enameled” on top of metal shells. It is tooth-colored and is used for crowns and fixed bridges

Advantages ❤ Good resistance to further

decay if the restoration fits well

❤ Very durable, due to metal substructure

❤ The material does not cause tooth sensitivity

❤ Resists leakage because it can be shaped for a very accurate fit

Disadvantages • More tooth must be removed

(than for porcelain) for the metal substructure

• Higher cost because it requires at least two office visits and laboratory services

GOLD ALLOY Gold alloy is a gold-colored mixture of gold, copper, and other metals and is used mainly for crowns and fixed bridges and some partial denture frameworks


decay if the restoration fits well ❤ Excellent durability; does not

fracture under stress ❤ Does not corrode in the mouth ❤ Minimal amount of tooth needs

to be removed

❤ Wears well; does not cause excessive wear to opposing teeth


Disadvantages • Is not tooth colored; alloy is

yellow • Conducts heat and cold; may

irritate sensitive teeth • High cost; requires at least two

office visits and laboratory services

DENTAL BOARD OF CALIFORNIA 1432 Howe Avenue • Sacramento, California 95825

www.dbc.ca.gov

Published by

CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS

5/04

The Facts About Fillings

The Facts About Fillings

DENTAL BOARD OF CALIFORNIA 1432 Howe Avenue • Sacramento, California 95825

www.dbc.ca.gov

Dental Materials Fact Sheet

What About the Safety of Filling Materials? Patient health and the safety of dental treatments are the primary goals of California’s dental professionals and the Dental Board of California. The purpose of this fact sheet is to provide you with information concerning the risks and benefits of all the dental materials used in the restoration (filling) of teeth.

The Dental Board of California is required by law* to make this dental materials fact sheet available to every licensed dentist in the state of California. Your dentist, in turn, must provide this fact sheet to every new patient and all patients of record only once before beginning any dental filling procedure.

As the patient or parent/guardian, you are strongly encouraged to discuss with your dentist the facts presented concerning the filling materials being considered for your particular treatment.

* Business and Professions Code 1648.10-1648.20

Allergic Reactions to Dental Materials Components in dental fillings may have side effects or cause allergic reactions, just like other materials we may come in contact with in our daily lives. The risks of such reactions are very low for all types of filling materials. Such reactions can be caused by specific components of the filling materials such as mercury, nickel, chromium, and/or beryllium alloys. Usually, an allergy will reveal itself as a skin rash and is easily reversed when the individual is not in contact with the material.

There are no documented cases of allergic reactions to compos-ite resin, glass ionomer, resin ionomer, or porcelain. However, there have been rare allergic responses reported with dental amalgam, porcelain fused to metal, gold alloys, and nickel or cobalt-chrome alloys.

If you suffer from allergies, discuss these potential problems with your dentist before a filling material is chosen.

2

PORCELAIN (CERAMIC) Porcelain is a glass-like material formed into fillings or crowns using models of the prepared teeth. The material is tooth-colored and is used in inlays, veneers, crowns and fixed bridges.

Advantages ❤ Very little tooth needs to be

removed for use as a veneer; more tooth needs to be re-moved for a crown because its strength is related to its bulk (size)

❤ Good resistance to further decay if the restoration fits well

❤ Is resistant to surface wear but can cause some wear on opposing teeth


❤ The material does not cause tooth sensitivity

Disadvantages • Material is brittle and can break

under biting forces • May not be recommended for

molar teeth • Higher cost because it requires

at least two office visits and laboratory services

NICKEL OR COBALT-CHROME ALLOYS Nickel or cobalt-chrome alloys are mixtures of nickel and chromium. They are a dark silver metal color and are used for crowns and fixed bridges and most partial denture frameworks.


decay if the restoration fits well

❤ Excellent durability; does not fracture under stress

❤ Does not corrode in the mouth ❤ Minimal amount of tooth needs

to be removed ❤ Resists leakage because it can

be shaped for a very accurate fit

Disadvantages • Is not tooth colored; alloy is a

dark silver metal color • Conducts heat and cold; may

irritate sensitive teeth • Can be abrasive to opposing

teeth • High cost; requires at least two

office visits and laboratory services

• Slightly higher wear to opposing teeth

The Facts About Fillings 7


GLASS IONOMER CEMENT Glass ionomer cement is a self-hardening mixture of glass and organic acid. It is tooth-colored and varies in translucency. Glass ionomer is usually used for small fillings, cementing metal and porcelain/metal crowns, liners, and temporary restorations.

Advantages ❤ Reasonably good esthetics ❤ May provide some help against

decay because it releases fluoride

❤ Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel

❤ Material has low incidence of producing tooth sensitivity

❤ Usually completed in one dental visit

Disadvantages • Cost is very similar to compos-

ite resin (which costs more than amalgam)

• Limited use because it is not recommended for biting surfaces in permanent teeth

• As it ages, this material may become rough and could increase the accumulation of plaque and chance of periodon-tal disease

• Does not wear well; tends to crack over time and can be dislodged

RESIN-IONOMER CEMENT Resin ionomer cement is a mixture of glass and resin polymer and organic acid that hardens with exposure to a blue light used in the dental office. It is tooth colored but more translucent than glass ionomer cement. It is most often used for small fillings, cementing metal and porcelain metal crowns and liners.

Advantages ❤ Very good esthetics ❤ May provide some help against

decay because it releases fluoride

❤ Minimal amount of tooth needs to be removed and it bonds well to both the enamel and the dentin beneath the enamel

❤ Good for non-biting surfaces ❤ May be used for short-term

primary teeth restorations

❤ May hold up better than glass ionomer but not as well as composite

❤ Good resistance to leakage ❤ Material has low incidence of

producing tooth sensitivity ❤ Usually completed in one dental

visit

Disadvantages • Cost is very similar to compos-

ite resin (which costs more than amalgam)

• Limited use because it is not recommended to restore the biting surfaces of adults

• Wears faster than composite and amalgam 6

Toxicity of Dental Materials

Dental Amalgam

Mercury in its elemental form is on the State of California’s Proposition 65 list of chemicals known to the state to cause reproductive toxicity. Mercury may harm the developing brain of a child or fetus.

Dental amalgam is created by mixing elemental mercury (43-54%) and an alloy powder (46-57%) composed mainly of silver, tin, and copper. This has caused discussion about the risks of mercury in dental amalgam. Such mercury is emitted in minute amounts as vapor. Some concerns have been raised regarding possible toxicity. Scientific research continues on the safety of dental amalgam. According to the Centers for Disease Control and Prevention, there is scant evidence that the health of the vast majority of people with amalgam is compromised.

The Food and Drug Administration (FDA) and other public health organizations have investigated the safety of amalgam used in dental fillings. The conclusion: no valid scientific evi-dence has shown that amalgams cause harm to patients with dental restorations, except in rare cases of allergy. The World Health Organization reached a similar conclusion stating, “Amal-gam restorations are safe and cost effective.”

A diversity of opinions exists regarding the safety of dental amalgams. Questions have been raised about its safety in preg-nant women, children, and diabetics. However, scientific evi-dence and research literature in peer-reviewed scientific journals suggest that otherwise healthy women, children, and diabetics are not at an increased risk from dental amalgams in their mouths. The FDA places no restrictions on the use of dental amalgam.

Composite Resin

Some Composite Resins include Crystalline Silica, which is on the State of California’s Proposition 65 list of chemicals known to the state to cause cancer.

It is always a good idea to discuss any dental treatment thoroughly with your dentist.

3


DENTAL AMALGAM FILLINGS Dental amalgam is a self-hardening mixture of silver-tin-copper alloy powder and liquid mercury and is sometimes referred to as silver fillings because of its color. It is often used as a filling material and replacement for broken teeth.

Advantages

❤ Durable; long lasting

❤ Wears well; holds up well to the forces of biting

❤ Relatively inexpensive

❤ Generally completed in one visit

❤ Self-sealing; minimal-to-no shrinkage and resists leakage

❤ Resistance to further decay is high, but can be difficult to find in early stages

❤ Frequency of repair and replacement is low

Disadvantages

• Refer to “What About the Safety of Filling Materials”

• Gray colored, not tooth colored

• May darken as it corrodes; may stain teeth over time

• Requires removal of some healthy tooth

• In larger amalgam fillings, the remaining tooth may weaken and fracture

• Because metal can conduct hot and cold temperatures, there may be a temporary sensitivity to hot and cold.

• Contact with other metals may cause occasional, minute electrical flow

The durability of any dental restoration is influenced not only by the material it is made

from but also by the dentist’s technique when placing the restoration. Other factors include the supporting materials used in the procedure and the patient’s cooperation during the procedure. The length of time a restoration will last is dependent upon your dental hygiene, home care, and diet and chewing habits.

4

COMPOSITE RESIN FILLINGS Composite fillings are a mixture of powdered glass and plastic resin, sometimes referred to as white, plastic, or tooth-colored fillings. It is used for fillings, inlays, veneers, partial and complete crowns, or to repair portions of broken teeth.

Advantages

❤ Strong and durable

❤ Tooth colored

❤ Single visit for fillings

❤ Resists breaking

❤ Maximum amount of toothpreserved

❤ Small risk of leakage if bondedonly to enamel

❤ Does not corrode

❤ Generally holds up well to theforces of biting depending onproduct used

❤ Resistance to further decay ismoderate and easy to find

❤ Frequency of repair or replace-ment is low to moderate

Disadvantages

• Refer to “What About theSafety of Filling Materials”

• Moderate occurrence of toothsensitivity; sensitive todentist’s method of applica-tion

• Costs more than dentalamalgam

• Material shrinks whenhardened and could lead tofurther decay and/or tempera-ture sensitivity

• Requires more than one visitfor inlays, veneers, andcrowns

• May wear faster than dentalenamel

• May leak over time whenbonded beneath the layer ofenamel

5

Signature ________________________________________________________

This is an acnowledgment that you have read the document:

We consider our office different from the average, ordinary dental office. Together we will create a Personalized Dental Plan tailored to your unique desires and needs. We realize that sometimes issues arise that you may not have considered, however; we promise to educate you, so that you are able to make the best decision. How long has it been since your last dental visit? What was it for? Do you have any areas of concern at this time? In your opinion, what is the present state of health of your mouth? What would you like to change about your smile? What did you like about your last dental office? Have you ever had a BAD experience at the dentist? If so briefly explain. What caused you to leave your last dental office? Do you know family or friends that come to our office? What are your expectations about our office? Has fear ever been and issue for you in a dental office? Have any of the following ever been a factor in putting off dental treatment? A) Fear B) Cost C) Feeling of necessity At what point will you allow us to initiate treatment? A) When it hurts B) When it breaks C) When we recommend treatment What Quality of dentistry do you want us to recommend? A) “Patch it” B) “What my insurance covers only” C) The ideal/The best Is there anything else you would like us to know? Name

Documents

1263 Pleasant Grove Blvd., Suite 150 Roseville, CA 95747 phn #: … · 2019. 4. 29. · To our patients: although oral surgeons primarily treat the area in and around your mouth,