Healthcare Dental Posts

DENTAL POST-OPERATIVE INSTRUCTIONS AND CONSENT

Practice Name:    Treating Provider:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Smoking/Tobacco Use:    Pregnant or Nursing:    Pacemaker / Implanted Device:

Procedure Details

Tooth/Area:    Scheduled Date:

Risks, Benefits, and Alternatives

I acknowledge that the treating provider has explained the nature of the proposed procedure, expected benefits, and reasonably foreseeable risks. Common and significant risks include infection, postoperative pain and swelling, damage to adjacent teeth or restorations, nerve irritation or injury, root fracture, failure of the post or restoration requiring retreatment or extraction, alteration of bite, and allergic reaction to materials or medications.

Reasonable alternatives, including no treatment, restoration without a post, or extraction and replacement options, were discussed with me. I have had the opportunity to ask questions and have received satisfactory answers.

I acknowledge that I understand the risks and alternatives described above.

Post-Operative Instructions (Summary)

Pain control: Expect discomfort for 24–72 hours. Use prescribed medications or recommended over-the-counter analgesics. Apply cold packs intermittently for the first 24 hours to limit swelling. Avoid heavy exertion for 48 hours.

Oral hygiene and diet: Avoid chewing on the treated side until permanent restoration is placed. Maintain gentle brushing and rinsing as instructed. Follow diet recommendations provided by the clinic.

Signs of complication: Contact the office if you experience uncontrolled bleeding, fever, severe or increasing pain, persistent swelling after 72 hours, numbness lasting longer than expected, or signs of allergic reaction.

Authorizations and Acknowledgments

Authorization to Treat: I authorize the treating dentist and dental staff to perform the procedure described above and to provide such routine and emergency care as is deemed necessary in the course of treatment. I consent to the administration of local anesthetic, sedation, and medications as indicated and discussed.

Assignment and Billing: I authorize the release of my dental and medical information to my insurance carrier(s) for the purpose of claims adjudication and payment. I authorize payment of benefits to the treating provider for services rendered. I understand that I am financially responsible for charges not covered by insurance.

Photographs and Records: I authorize clinical photography, radiographs, and other records as necessary for diagnosis, treatment planning, and documentation. Such records may be used for treatment, consultation, or educational purposes with identifying information removed unless I expressly consent otherwise.

I consent to clinical photographs/radiographs as part of my care.

HIPAA Privacy and Release

I acknowledge receipt of the practice's Notice of Privacy Practices and authorize the practice to use and disclose my protected health information for treatment, payment, and healthcare operations in accordance with applicable law.

Expiration of Authorization: This authorization will expire on:

Patient Certification

By signing below I certify that I have read and fully understand this consent and post-operative instruction document; that the information I have provided is complete and accurate to the best of my knowledge; that the nature and purpose of the proposed procedure, the probable risks and benefits, and reasonable alternatives have been explained to me; and that I have had the opportunity to ask questions and receive answers. I consent to the performance of the procedure and to the necessary ancillary services described herein.

Sign Now