Consent Form For Cosmetic Treatment

  • I, THE UNDERSIGNED, CONSENT TO Dr. Neetu Chopra, her partners, associates, dental hygienists, and/or dental assistants performing on me the outlined Treatment Plan (as outlined on the "Treatment Form" that has been provided to me).

  • I accept and understand that the procedures are elective in nature and not treatment for any dental disease.

  • I accept and understand that although Dr. Chopra will make every effort to improve my smile to my desires, there are limitations due to function, color, extent of inherent staining, shape and/or placement of the original teeth.

  • I accept and understand that cosmetic results are subjective; thus, the outcome of my Cosmetic Treatment Plan may not completely meet my expectations.

  • I accept and understand that the alternatives to the Cosmetic Treatment Plan, which have been fully discussed with me, include but are not exclusive of:

    • Orthodontic Treatment

    • No Treatment

  • Each option has been fully explained to me with its' benefits, risks, pros, cons and approximate investment cost. I accept and understand that there are risks and limitations to all procedures. For this cosmetic treatment these risks and limitation include, but are not exclusive of:

    • Pain in the jaw.

    • Chipping of restorations

    • Change in speech

    • Change in appearance.

    • Need/or elective root canal therapy (at additional cost)

    • "Show Through" of inherent staining over time.

    • The cosmetic changes are permanent and, although they can be changed again, they cannot go back to how they were originally.

  • I have had the opportunity to discuss the Cosmetic Treatment Plan, and have had an opportunity to ask questions, and am fully satisfied with the answers received.

  • If, during the procedure, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.

  • I accept and understand that, as with any medical or dental procedure, there are no guarantees as to the longevity of the work performed. I also accept and understand that the Cosmetic Treatment Plan does not contain any warranty against loss of teeth due to disease.

  • I accept and understand that I play a major role in the maintenance of my teeth and restorations.

  • I agree to maintain good oral hygiene and keep regular dental check-ups and cleaning appointments with Dr. Chopra at least every 6 months.

  • I agree to wear my night guard every night as instructed and to follow all instructions given to me.

  • I understand that photographs may be taken of the procedures, and hereby give my consent to those photographs being taken, as well as my consent to before and after photographs being taken. I also understand and consent to those photographs being used for and in documentation, diagnosis, and treatment planning.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.