Consent Form

Treatment room at Sunrise Dentistry with a dental chair beside floor-to-ceiling windows

For Patients

New Patient
Consent

Consent for a new patient exam, X-rays, dental fillings, hygiene cleaning and local anesthesia. Please read each section and sign at the end.

This form asks for personal health information, which will become part of your office record and will be held in strict confidence. If you have any questions, please call us at 416-626-0473.

Sunrise Dentistry

5555 Eglinton Ave W, Etobicoke, ON, M9C 5M1 Phone: 416-626-0473

Today's Date

Consent Form for New Patient Exam, X-rays, Dental Fillings, Hygiene Cleaning, and Local Anesthesia

Patient Name

Date of Birth

Dentist Name

Treatment Date

Treatment Description

As a new patient, I understand that a comprehensive dental examination will be performed, which may include

Review of medical and dental historyVisual examination of teeth and gumsDigital or traditional X-raysIntraoral photographs (if needed)Dental hygiene cleaning (scaling and polishing)Administration of local anesthesia if requiredDental fillings using composite (tooth-colored) or amalgam materials if cavities are diagnosed

Purpose of Treatment

The purpose of the examination and X-rays is to evaluate my oral health and detect any problems that require treatment. Dental hygiene cleaning helps remove plaque, tartar, and stains, improving gum health. Dental fillings are intended to restore teeth affected by decay or minor fractures and to prevent further deterioration. Local anesthesia may be administered to reduce discomfort during treatment.

Treatment Alternatives

I understand that alternatives may include

No treatment (with potential worsening of oral health)Delaying treatment (with risk of pain, infection, or more complex procedures later)Extraction or other restorative procedures if fillings are not suitable

Risks and Complications

I understand that

Fillings may cause temporary sensitivity to hot, cold, or pressureA filling may not resolve all symptoms, and further treatment (e.g., root canal) may be requiredCleaning may result in temporary gum soreness or bleedingDeep cleaning may reveal sensitivity due to exposed root surfacesX-rays involve minimal radiation exposure and are performed with protective measuresLocal anesthesia may cause temporary numbness or mild allergic reactions

Post-Treatment Instructions

I will follow instructions provided by the dental team, including

Avoid chewing hard foods until numbness wears offReport any prolonged pain, sensitivity, or discomfortMaintain good oral hygiene and attend regular dental visits

Consent

I have had the opportunity to ask questions about the dental examination, X-rays, cleaning, fillings, and local anesthesia. I understand the procedures, risks, benefits, and alternatives. I voluntarily consent to the proposed treatment.

Patient Signature

Sign inside the box, or type your full name below.

Signature Date

Dentist/Witness Signature (for use by Dentist/Clinic only)

Witness Date