I understand that porcelain veneer treatment may entail certain risks and possible
unsuccessful results, with even the possibility of failure to achieve the results which may be
desired or expected. I agree to assume those risks or possible unsuccessful results but are not
limited to the following:
1. Reduction or roughening of tooth structure: Making preparation of teeth for the reception
of porcelain veneers, it is necessary to slightly reduce or roughen the surface of the tooth to
which the veneer(s) may be bonded. This preparation will be done as conservatively as
possible. If the veneer covering breaks or comes off, the uncovered tooth may become more
decay susceptible. The tooth may require replacement with another veneer or crown.
2. Sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of
treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any
length of time, please contact the office for an examination.
3. Chipping, breaking or loosening of the veneer: No matter how well done, this could occur.
Many factors may contribute to this happening such as: chewing of hard materials; changes in
occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and
other such conditions over which the doctor has no control.
4. Esthetics and appearance : Every effort possible will be made to match and coordinate both
the form and shade of veneers which will be placed in order to be cosmetically pleasing to the
patient. However, there are some differences which may exist between the natural dentition and
the materials which are artificial, making it impossible to have the shade and/or form perfectly
match your natural dentition.
5. Longevity: it is impossible to place any specific time criteria on the length of time that
veneers should last for. These time periods may vary from a very short time to a very long time
depending upon many conditions existing from patient to patient, and/or upon each patient’s
individual habits or circumstances, which may be either internal, external or both. Even though care
and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or
desired results nor the longevity of the treatment.
**** It is the patient’s responsibility to immediately inform the doctor and seek attention from
him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all
instructions must be diligently followed, including scheduling and attending all appointments.
INFORMED CONSENT FOR VENEER PREPARATION AND CEMENTATION
I have been given the opportunity to ask any and all questions regarding the nature and
purpose of porcelain veneer treatment and have received all answers to my satisfaction. I voluntarily
assume any and all possible risks, including the risk of substantial harm, if any, which may be
associated with any phase of this treatment in hopes of obtaining the desired results, which may or
may not be achieved.
No guarantees or promises have been made to me concerning the results. The fee(s) for
these services have been explained to me and are satisfactory. By signing this form, I am freely
giving my consent to allow and authorize my Doctor to render any treatment deemed necessary,
desirable, and/or advisable to me, including the administration and/or prescribing of any anesthetics
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and submitting this document, we are assuming that it has been read in its entirety.
All patient signatures will be verified for authenticity in the office.