GENERAL CONSENT FORM

Dear Patient, Please read the information given below. By reading and signing this information, you will have information about the treatments that will be applied to you or your child. Learning the benefits and risks of treatment planning will make you satisfied at the end of the treatment. Wishing you a healthy and happy life.During the treatments, limited numbing is applied to provide pain control. When necessary, first of all, the gingiva or the inner part of the cheek is anesthetized with a topical anesthetic agent (spray). When the area becomes numb, the anesthetic liquid is injected with a syringe and the tooth and the area are numbed for a while. Allergic reactions, loss of sensation, bleeding, temporary muscle spasms, temporary facial paralysis may be seen in patients, although rare, after local anesthesia application. Local anesthesia is a successful application as long as there are no anatomical differences or acute infections in the region. The area where local anesthesia is applied is numb for about 2-4 hours. For this reason, it is not recommended to eat and drink until the numbness subsides, in order to avoid wounds on the cheeks and lips due to the bite. After 2-4 hours, the effect of anesthesia disappears. During your treatments, biopsy may be required for further examination. Take care to be faithful to your appointments and to arrive on time so that our health institution, its order and treatment program are not disrupted. If you cannot come, cancel your appointment 24 hours in advance.Tooth extraction; Whether it is a difficult or routine extraction, it is a surgical procedure and is irreversible. As with any surgical procedure, there are some risks. These risks can be listed as but not limited to the following: 1. Swelling and/or redness, discomfort in the surgical area, 2. Redness and cracking due to stretching at the corners of the mouth, 3. Development of infection and delayed healing of the wound, 4. Dry socket; jaw pain that begins a few days after surgery, often due to inadequate care; It is more common in lower jaw extractions, especially in wisdom teeth. 5. Damage to the adjacent tooth, especially in the presence of large fillings and crowns, 6. Loss of sensation or decreased sensation in the gums, lip, tongue, teeth and jaw tip. It can be seen especially in teeth with roots close to nerves, such as wisdom teeth. Numbness almost always returns to normal, but very rarely it can be permanent. 7. Trismus; It is a limitation in opening the mouth due to inflammation or swelling. 8. Bleeding-severe bleeding is not common. But bleeding in the form of leakage continues for several hours. 9. Sharp corners and bony steps may occur in the shooting cavities after extraction. These are corrected with a new surgical intervention. 10. Incomplete removal of root fragments. Sometimes small pieces of root can be left in order not to damage important formations such as sinuses or nerves. 11. Sinus relationship; the roots of the maxillary posterior teeth are very close to the sinuses, and in some cases, root fragments may escape into the sinus or an opening may form between the sinuses and the mouth; These situations need special attention. 12. Jaw fractures; Although it is very rare, it is possible to occur in difficult and deeply impacted tooth extractions.I have understood that root canal treatment is a procedure to save the tooth from being pulled out. I learned that although root canal treatment has very successful clinical results, it is a treatment that can never be guaranteed because it is a biological process. I have understood that the small instruments used in the root canal during the treatment have a slight chance of breaking and this may adversely affect the success of the treatment. I was informed that in some cases, especially in teeth with periapical lesions, if there is no improvement after root canal treatment, repeat root canal treatment, surgical intervention and sometimes tooth extraction may be necessary.

 

GENERAL CONSENT FORM

Dear Patient, Please read the information given below. By reading and signing this information, you will have information about the treatments that will be applied to you or your child. Learning the benefits and risks of treatment planning will make you satisfied at the end of the treatment. Wishing you a healthy and happy life.During the treatments, limited numbing is applied to provide pain control. When necessary, first of all, the gingiva or the inner part of the cheek is anesthetized with a topical anesthetic agent (spray). When the area becomes numb, the anesthetic liquid is injected with a syringe and the tooth and the area are numbed for a while. Allergic reactions, loss of sensation, bleeding, temporary muscle spasms, temporary facial paralysis may be seen in patients, although rare, after local anesthesia application. Local anesthesia is a successful application as long as there are no anatomical differences or acute infections in the region. The area where local anesthesia is applied is numb for about 2-4 hours. For this reason, it is not recommended to eat and drink until the numbness subsides, in order to avoid wounds on the cheeks and lips due to the bite. After 2-4 hours, the effect of anesthesia disappears. During your treatments, biopsy may be required for further examination. Take care to be faithful to your appointments and to arrive on time so that our health institution, its order and treatment program are not disrupted. If you cannot come, cancel your appointment 24 hours in advance.Tooth extraction; Whether it is a difficult or routine extraction, it is a surgical procedure and is irreversible. As with any surgical procedure, there are some risks. These risks can be listed as but not limited to the following: 1. Swelling and/or redness, discomfort in the surgical area, 2. Redness and cracking due to stretching at the corners of the mouth, 3. Development of infection and delayed healing of the wound, 4. Dry socket; jaw pain that begins a few days after surgery, often due to inadequate care; It is more common in lower jaw extractions, especially in wisdom teeth. 5. Damage to the adjacent tooth, especially in the presence of large fillings and crowns, 6. Loss of sensation or decreased sensation in the gums, lip, tongue, teeth and jaw tip. It can be seen especially in teeth with roots close to nerves, such as wisdom teeth. Numbness almost always returns to normal, but very rarely it can be permanent. 7. Trismus; It is a limitation in opening the mouth due to inflammation or swelling. 8. Bleeding-severe bleeding is not common. But bleeding in the form of leakage continues for several hours. 9. Sharp corners and bony steps may occur in the shooting cavities after extraction. These are corrected with a new surgical intervention. 10. Incomplete removal of root fragments. Sometimes small pieces of root can be left in order not to damage important formations such as sinuses or nerves. 11. Sinus relationship; the roots of the maxillary posterior teeth are very close to the sinuses, and in some cases, root fragments may escape into the sinus or an opening may form between the sinuses and the mouth; These situations need special attention. 12. Jaw fractures; Although it is very rare, it is possible to occur in difficult and deeply impacted tooth extractions.I have understood that root canal treatment is a procedure to save the tooth from being pulled out. I learned that although root canal treatment has very successful clinical results, it is a treatment that can never be guaranteed because it is a biological process. I have understood that the small instruments used in the root canal during the treatment have a slight chance of breaking and this may adversely affect the success of the treatment. I was informed that in some cases, especially in teeth with periapical lesions, if there is no improvement after root canal treatment, repeat root canal treatment, surgical intervention and sometimes tooth extraction may be necessary.

 

Hekimin Adı-Soyadı:  {doktorad}

DİŞ ÇEKİMİ HASTA ONAM FORMU

  • In order to inform you and get your consent to start your treatment, you must read this form, fill in and sign the sections at the end.Thank you for your participation and your time.Tooth extraction; Whether it is a difficult or routine extraction, it is a surgical procedure and is irreversible.As with any surgical procedure, there are some risks. These risks can be listed as but not limited to the following:1. Swelling and/or redness, discomfort at the surgical site,2. Redness and cracking due to stretching in the corners of the mouth,3. Development of infection and delayed healing of the wound,4. Dry socket; jaw pain that begins a few days after surgery, often due to inadequate care; It is more common in lower jaw extractions, especially in wisdom teeth.5. Damage to the adjacent tooth, especially in the presence of large fillings and crowns,6. Loss of sensation or decreased sensation in the gums, lips, tongue, teeth and jaw tip. It can be seen especially in teeth with roots close to nerves, such as wisdom teeth. Numbness almost always returns to normal, but very rarely it can be permanent.7. Trismus; It is a limitation in opening the mouth due to inflammation or swelling.8. Bleeding-severe bleeding is not common. But bleeding in the form of leakage continues for several hours.9. Sharp corners and bony steps may occur in the shooting cavities after extraction. These are corrected with a new surgical intervention.10. Incomplete removal of root fragments. Sometimes small pieces of root can be left in order not to damage important formations such as sinuses or nerves.11. Sinus relationship; the roots of the maxillary posterior teeth are very close to the sinuses, and in some cases, root fragments may escape into the sinus or an opening may form between the sinuses and the mouth; These situations need special attention.12. Jaw fractures; Although it is very rare, it is possible to occur in difficult and deeply impacted tooth extractions. Most surgical procedures are routine and major complications are not expected. Complications that occur are also minor and easily treatable conditions.Tooth to be extracted:

Hasta veya Hastanin Yasal Temsilcisi* – Yakinlik Derecesi

MOVABLE PROSTHESIS CONSENT FORM

Hareketli bölümlü protez terimi genellikle hastanın eksik dişlerinin yerine yapılan ve kendisinin takıp çıkartabildiği protez anlamında kullanılmaktadır. Bu tip protezler ağızda kalmış dişler ve dişleri çevreleyen yumuşak dokulardan da destek alınarak yapılır. Metal kancalardan (kroşe) ya da hazırlanan metal bağlantılardan yararlanabilir. Hassas bağlantı estetik avantajlara sahip olmakla birlikte, destek dişlerin sabit protezle kaplanması gibi dezavantajlara da sahiptir. Bölümlü protez yapımı sırasında daha iyi bir uyum ve tutuculuk sağlayabilmek için doğal diş üzerinde aşındırmalar yapılabilir. Bazen bir ya da birkaç destek dişin kaplanması gerekebilir. Hareketli bölümlü protezler diş eti rengindeki (akrilik) bir alt yapı üzerine yapılabildikleri gibi metal ve akrilik birlikte de hazırlanabilir. Protezin dengesi açısından çenenin her iki tarafında da tutucu elemanları olmalıdır. Bu nedenle üst çenede damakta ve alt çenede ön dişlerin arkasında iki tarafı bağlayan bir ana parçası vardır. Eksik dişler yerine ise, yine akrilik hazır takım dişler kullanılır.  Aşırı diş ve kemik doku kayıpları nedeniyle bölümlü protezlerde yeterli tutuculuk sağlanamayabilir. Hareketli bölümler protezler yapımı sonrası vuruk, protezin metal iskeletinde bükülme ya da kopma, akrilik bölümlerde çatlak ya da kırılma gibi sorunlar oluşabilir. Bu sorunlar protezi yapan hekim tarafından giderilir ancak hastadan kaynaklı sorunların giderilmesi için gerekli masraf hasta tarafından karşılanır.

  1. Protezin altina yiyecek artiklari birikmesi.
  2. Konusmada zorluk.
  3. Protez kenarinda olusan “protez vuruklari”: Kontrol randevularinda hekimin yapacadi birtakim düzenlemelerle bu sikayetler de giderilir.

  1. Birinci ölçü
  2. Ikinci ölçü
  3. Birinci Prova: Kapanis provasi
  4. Prova; Dislerin kontrolünün yapildigi prova: Bu seansta dislerin rengi, boyutu, sekli ve düzeni konusunda hasta ve yakinlarinin imzali onayi alinir.
  5. Protezin Hastaya teslimi

Kullanacadim “TAM PROTEZ” hakkinda, bu saglik kurulusunda tedavimden sorumlu olan dis hekimi

  1. Uygulanacak olan “Tam Protez”in yapay bir organ oldugunu ve hiçbir zaman kendi dislerim gibi islev göremevecedini anlivor ve kabul edivorum.
  2. “Tam Protez” kullaniminin zor oldugunu ve alismak için zamana ihtiyacim oldugunu anliyor ve kabul ediyorum.
  3. “Tam Protez” kullanirken zaman zaman protez vuruklarina ba§li agril bölgeler olabilecedini kabul ediyorum.
  4. “Tam Protez” kullanirken konusmamin degisebilecegini kabul ediyorum.
  5. “Tam Protez” kullanirken görünümümün degisebilecegini kabul ediyorum.
  6. “Tam Protez”min yapimi sirasinda saglik kurulusunuza en az 6 seans gelmeyi kabul ediyorum.

Hasta veya Hastanin Yasal Temsilcisi* – Yakinlik Derecesi

IMPLANT CONSENT FORM

Dear patient/ his/her legal representative;To be informed about your health / patient's health status and all kinds of medical, surgical or diagnostic procedures recommended to you / your patient and their alternatives, benefits, risks and even possible harms and reject or accept all or some of them or You have the right to stop the actions to be taken at any stage.This document, which we want you to read and understand, has been prepared not to frighten you or to keep you away from medical practices, but to inform you and get your consent in determining whether you will consent to these practices.

INFORMATION ABOUT THE PROCESS

Dental implants are artificial tooth roots that are placed in the jawbone and made of suitable materials in order to restore the function and aesthetics of missing teeth. dental implants; It can be easily applied in the elimination of a single missing tooth without touching the neighboring healthy teeth, in the elimination of more than one missing tooth by making fixed bridges with the help of implants instead of removable dentures, in making fixed prostheses instead of removable dentures (palate) in case of complete edentulism, in eliminating all kinds of edentulism and missing functions. .Implant applications are a surgical procedure and are performed under local anesthesia. Before the operation, your doctor verbally informed you about the procedures to be performed. Following the advice of your doctor after the operationaspect is extremely important.

ALTERNATIVE TREATMENTS

Bridge Prosthesis or Removable Prosthesis can be applied.To inform1- As with all surgical procedures, your general health is closely related to the success of implant surgery. Some of the complications that may arise may be related to your general health condition.2- There may be swelling, pain and skin discoloration in the area after the operation.3- There may be damage to the anatomical structures in the implanted area. Accordingly, there may be complaints such as permanent or temporary numbness in the lower lip, bleeding from the nose as a result of injury to the maxillary sinus or inflammation.4- There may be loosening or falling off the closing screws placed on the implant.5- In some cases, it may be necessary to remove the placed implant and replace it with a new one as a result of the delay or failure of the healing of the implant.6- After the implant treatment, the healing of the gingiva takes about 10 days, while the healing of the bone may take about 3-4 months in the lower jaw and 5-6 months in the upper jaw. In cases where bone addition to the sinus is required, healing in the upper jaw may take up to 9 months.7- It is important that you strictly follow the recommendations that your doctor has told you after the implant operation. In case of non-compliance, some undesirable situations may occur.8- If necessary, synthetic or animal-derived bone and similar materials are used during implant applications. If you do not want to use these substances, please inform your doctor.To informAdhering to your doctor's warnings and recommendations will increase your chances of success. However, this treatment may also fail due to biological reasons.I have read the information described above and have been informed by the undersigned doctor. I was informed about the purpose of the intervention, its risks, complications and additional treatment interventions. I consciously approve this transaction without any further explanation, without any pressure.Name-Surname: {name-surname}Patient Number: {hospital}Date: {date}

Hasta No:   {hastano}