THPDental - Consent for Restoration

Personal Information

Patient Name*

After in depth discussion about advantages and disadvantages and being advised of alternatives, I have opted for the following procedure:

I have been advised by of Dr. Sandra Hulac that the average prognosis of these restorations is, after which time they will have to be replaced.

years and their longevity depend on may care, my diet and regular attendance for examinations and hygiene appointments.

Chipping of these restorations is a common occurrence; repairs can usually be carried out but at cost.

CONSENT

Name of Patient / Parent / Legal Guardian*

Patient's / Parent's / Guardian's signature*

Relationship with patient*