AGREEMENT AND INFORMED CONSENT

This Agreement (“Agreement”) governs your use of the services of PAYLIP DENTAL CLINIC (as defined
below). By engaging our services, you agree that you have read, understand and consent to this Agreement:
Service Acceptance/Informed Consent to Dental Services.

● You agree and have the legal right and ability to: (i) enter into this Agreement, (ii) receive Dental
Services for your personal benefit or the benefit of your legal minor children, and (iii) abide by the
obligations, including the Terms and Conditions, set forth in the Agreement.

● You acknowledge and agree that you are making an informed decision to enter into this Agreement and
to receive the Dental Services, and have been given all necessary and relevant information to make
that decision.

● You agree to select a Dental Practice as your primary service provider for Dental Services and to
receive Dental Services .

● You agree by accepting the Dental Services that you and/or your minor child if applicable are a patient
and are entering into a patient-provider relationship with the dental professional(s) .

● You hereby authorize the Dentist to administer such medications and perform such diagnostic,
photographic and therapeutic procedures as may be necessary for proper dental care in accordance
with the Consent to Treatment, set forth in this Agreement.

● You agree that any prescriptions of medication for dental treatment that you receive shall be solely for
your personal use or the use of your legal minor child.

● You understand that there are potential risks associated with receiving Dental Services, including the
potential risks of infections and/or breaches of privacy of personal information. A partial listing of the
risks known to be associated with this treatment and with associated anesthetic are listed below:
● Change of bite ● Paresthesia (permanent or transient
● Loss of taste numbness of the cheeks, gums,
● Drug/allergic reaction teeth, lips, tongue, chin & face)
● Dry socket Infection ● Stretching of the skin that may result
● Fractured/broken root(s) in cracking & bruising
● Retained root fragments ● Failure of the treatment to
● Loss/damage to adjacent teeth & accomplish its purpose
bone ● Bleeding which may be heavy
● Fractured or broken jaw enough to stop procedure
● Sinus involvement ● TMJ dysfunction or worsening of
● Further surgery or treatment TMJ condition
● Pain ● Swallowing/Inhaling objects
● Broken instrument ● Trismus (pain in the jaw leading to
● Swelling & bruising difficulty opening)
● Retained instrument fragment(s)

● You agree not to seek opinions from other dental professionals while engaging in treatment from our
clinic to practice professional ethics and patient to doctor confidentiality.

● You agree to fully and carefully read all information provided to you, any follow-up instructions, and
prescribed medications.

TERMS AND CONDITIONS

● The Patient is responsible for providing accurate information, in the forms and the dental/medical
histories are correct to the best of your knowledge, and for updating any demographic information, in
the dental record.
● It is clear to the patient that he/she will undergo compensatory treatment even before we carry on with
the initial treatments. Secondary treatment corrections will be initiated after finding out what went wrong
on the first compensatory treatment done by taking necessary 2D x-rays diagnostic casts and will
undergo discussions about the treatment plan that will take place to compensate the bite on the extent
of his/her existing dental conditions and paid restorations only.
● The clinic will replace, if needed be the affected installed crown with the same material quality only.
● Crown Upgrade such as converting into more aesthetic considerations shall only be allowed provided
that the patient will agree to add an additional fee for chosen crown.
● It is clear to the patient that, undergoing such procedures will take time to re-adjust the bite considering
the laboratory work flow and craftsmanship, materials needed, temporization, assessment and doctor’s
availability. This agreement will help the patient assure that we are motivated to correct her bite with
our moral obligations to help her balance her bite until we accomplish it by taking her final radiographs
and bite analysis.
 ● The Patient agrees to follow all recommendations, protocols and other instructions provided by Paylip
Dental Clinic in order to achieve bite equilibrations. Any treatment recommendations that are beyond or
was discussed particularly Root Canal Procedures but the patient refused to undergo it initially but is
necessary shall not be offered again in our clinic instead we will refer her to another clinic for us to just
remain with the agreed procedures only.

● Crowns that are needed to be corrected shall be replaced with the Same materials agreed upon (tilite
pfm crowns) will be used for the restoration of teeth affected if needed be only and with no extra fees
will be collected for correcting bite equilibrations.

● Disinfection fees include PPE, instrument disinfection, dental treatment chamber sterilization shall be
paid by the patient every dental procedure will be performed.

__________________________________________________
Patient’s/ Patient’s Guardian Signature over printed name

Date:_________________

__________________________________________________
Dentist’s Signature over printed name

Date:_________________