Filling Consent Form

Patient Name: ____________________________
Date of Birth: ____________________________
Dentist’s Name: ____________________________
Date of Procedure: ____________________________

Procedure Explanation

I understand that composite resin is a tooth-colored filling material used to restore decayed, chipped, or damaged teeth. The procedure involves removing decay or damage, applying the composite resin material, and curing it with a special light to harden and bond it to the tooth.

Benefits of Composite Resin Fillings

• Aesthetically matches natural teeth.
• Preserves more of the natural tooth structure.
• Provides strong and durable restoration.

Risks and Limitations

I acknowledge that, like any dental treatment, composite resin restorations have potential risks, including but not limited to:

• Possible sensitivity to hot and cold after the procedure.
• Composite fillings may wear down or stain over time.
• The filling may chip, crack, or require replacement in the future.
• There is a small risk of needing further treatment, such as a root canal, if decay is extensive.
• Some staining or discoloration may occur over time.

Alternative Treatment Options

I understand that alternative treatments may include:

• Amalgam (silver) fillings.
• Ceramic or gold restorations.
• No treatment, understanding that decay may worsen.

Post-Treatment Care

I understand that:

• I should avoid chewing hard foods on the treated tooth for 24 hours.
• I may experience temporary sensitivity, which should subside.
• Regular dental check-ups are necessary to monitor the filling’s condition.

Consent & Acknowledgment

I have had the opportunity to ask questions and fully understand the procedure, risks, benefits, and alternatives. I consent to receiving a composite resin restoration as recommended by my dentist.

Patient’s Signature: ____________________________
Date: ____________________________

Dentist’s Signature: ____________________________
Date: ____________________________