Please read and initial the work to be done below, then read and sign the section at the bottom of the form. DRUGS AND MEDICATION I understand that antibiotics, analgesics and other medications may cause allergic reaction causing redness, swelling of tissues, pain, itching and vomiting, and/or anaphylactic shock. I understand that the administration of local anesthetics may result in temporary or permanent paresthesia (numbness) of involved teeth, tissues, and associated structures. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain, and potential resistance to effect treatment of my condition. I accept these risks by consenting to the use of local anesthetics during my dental appointments. If I have a medical condition that necessitates antibiotic pre-medication before dental treatment, it is my responsibility to notify the dentist. I assume all responsibility for all medical consequences if the dental office is unaware of my need for pre-medication. * Clear Signature MILPITAS SQUARE DENTAL retains sole discretion to determine whether repair or replacement is appropriate. Warranties are subject to the following conditions and exclusions: * • You must remain a patient of the practice and maintain your preventative care visits at our office at six (6) monthly intervals (Preventive care includes cleaning treatment, exams, x-rays and topical fluoride treatments) so we can ensure your underlying dental health. • Recurrent decay due to poor patient oral hygiene is exclude. • Restoration failure due to misuse (e.g., chewing ice, removing bottle caps with your teeth, accident damage, habitual damage such as nail biting etc.) is excluded • Should a restoration need to be removed or be damaged repairing a dental problem related to the tooth on which it is placed (e.g., root canal under a crown, or decay of the teeth supporting a fixed bridge), the warranty does not apply. • If there is a general illness occurring that has negative effects on the dental conditions (e.g., diabetes, epilepsy, osteoporosis, conditions after X-rays or chemo therapy) the warranty does not apply. • Warranty is void if products is installed/reinstalled or serviced by anyone other than our practice • Change due to patient's perception of the aesthetics of the final case (referred to as preference towards the appearance of their teeth e.g., change in color, size, brand and type) after completion is excluded from the warranty. We warrant (dentures) for one year from the date of replacement. The acrylic base (pink material will not fracture or teeth de-bond when the appliance is used in strict compliance with approved indications and instructions. We make no other warranties, including, but not limited to, an implied warranty of merchantability or fitness for a particular purpose. Our sole obligation and the customer's sole remedy in case of any breakage or de-bonding of the appliance shall be limited to the replacement or repair by us, bringing the unit under warranty to replace or fix. This warranty does not cover breakage or de-bonding resulting from an accident or misuse. Standard post-delivery care (adjustments) is provided at no charge during the warranty period. Excluded are relines rebases and any post-delivery design to the appliance. Limitation of Liability Except where prohibited by law. We will not be liable for any loss or damages arising from this product, whether direct, indirect, special, incidental, or consequential, regardless of the theory asserted, including warranty, contract, negligence, or strict Liability. Suppose a course of treatment recommended by a dentist needs to be followed, or an alternative treatment course is chosen instead of the recommended treatment plan. In that case, a dental warranty will not cover the treatment. A dentist will indicate the applicability of the dental warranty concerning the course of treatment followed. In extreme rehabilitative or reconstructive cases, the dentition may be compromised to the extent that even complicated, high-quality prosthesis may have a guarded or poor long-term prognosis. In such cases, a standard warranty cannot be provided. A dentist will indicate the applicability or non-applicability of a warranty. We aim to provide you with the very best possible standard of dental care tailored to meet your specific needs and to do this in the most timely manner and with the utmost comfort. We want you to have a positive experience with us and gain the best treatment outcome. Your adherence to these preceding terms and conditions of treatment will allow us to provide the best care for you. * Clear Signature PROCEDURE TO BE PERFORMED: * Please Select PARTIAL DENTURES FULL DENTURES INTERIM DENTURES MOUTH GUARD NIGHT GUARD OTHERS
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PARENT/LEGAL GUARDIAN (if minor) *
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