PATIENT’S MEDICAL & DENTAL HISTORY

Details filled in this form are CONFIDENTIAL as per the Court of Law. No details filled herein
shall be divulged to a third party without express permission of patient, guardian, or unless advised
in writing by the court/ law enforcing agency)
Do you suffer from any of the following conditions:
❑ Asthma ❑ Herpes
❑ High/ Low Blood Pressure ❑ Fungal Infections anywhere on body
❑ Cardiac (Heart) Problems ❑ Bleeding Disorders
❑ Diabetes (Sugar Problem) ❑ Stomach or Intestinal Ulcer
❑ Epilepsy ❑ Cancer
❑ Food or Drug Allergies ❑ Joint Problems
❑ Sexually Transmitted Disease ❑ Migraine
❑ TB (Tuberculosis) ❑ Lung Diseases
❑ HIV/ AIDS ❑ Kidney Problem
❑ Contagious Diseases/ Lesions ❑ Liver Problem

Have you been hospitalized in past six months? Yes No

For what reason? __________________________________________________________________

__________________________________________________________________
__________________________________________________________________

Are you presently taking any medication? (Please write the names in clear writing)
________________________________ ________________________________

________________________________ ________________________________

________________________________ ________________________________

________________________________ ________________________________

What DENTAL treatments have you undergone in past?

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Did you face any problem like excessive bleeding, rashes, breathing difficulty, vertigo, headaches,
stomach upset etc during previous dental visits?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

PHYSICIAN’S NAME & CONTACT NUMBER:

_______________________________________________________________________________
 PATIENT’S MEDICAL & DENTAL HISTORY

Kindly read and understand the importance of providing your past and present medical or dental
history to your treating doctor:
• Your medical history can help us understand the origin of your dental problem.
• It also helps us understand what medicines are not suitable for you, what to avoid and what
to prescribe.
• Your dental history helps us understand the conditions you are susceptible to, eg. Cavities,
Ulcers or maybe Gum Infections.
• A clear understanding of ongoing medical treatments & medications helps us to avoid drug
unwanted interactions which can cause serious harm to your health.
• Such details also help us in scheduling your appointments and treatments in accordance to
the physician’s instructions.
• It also helps us keeping emergency drugs handy in case you require them.

PLEASE PROVIDE US YOUR COMPLETE MEDICAL AND DENTAL HISTORY AS PER THE
BEST OF YOUR KNOWLEDGE.

• If a patient hides information about his or her past & present medical conditions and drugs,
they can be held liable and legal action can be taken against them.
• Legal action can be taken AGAINST patient for failure in treatment resulting due to non
disclosure of medical conditions.
• Neither the patient, nor the doctor can be held responsible for allergic reactions occurring
because of the chemicals & medicaments used during treatment or due to drugs prescribed,
against which patient has had no previous exposure, reactions, allergies or interactions.
• Our team suggests you to undergo allergy and drug reaction profiling before undergoing
any medical or dental treatment, to reduce the chances of being dozed with a drug you are
hypersensitive against.
• Such tests, however, can only reduce the chances of reactions (and not completely prevent
it), by helping doctors to avoid prescribing or using commonly known chemicals.

I, __________________________________________, have, to the best of my knowledge,

provided Dr.___________________________________________, my past and present medical
& dental history. I hereby assure that I have not hidden any known medical data. I understand
that in case I am found guilty of withholding medical/ dental data that might result in partial
or complete failure of my treatment, I would be solely responsible for the same.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 TREATMENT CONSENT FORM

I,________________________________________________, hereby give my consent and authorize

Dr. Vaibhav Nepalia/ Dr. Gunjan Singh, their team, consultants,s and supporting staff to perform all

procedures required for the treatment including but not limited to diagnostic models, radiographs,

photographs, extractions and administration of local anesthesia or other medication.

• I understand that during treatment, it may be necessary to change or add to the planned
procedures because of conditions discovered during the treatment that were not evident during
examination. I understand and authorize the doctors to use their best professional judgment to
provide the appropriate care even when this represents a change in the diagnosed problem and
course of treatment.
• I acknowledge that no guarantees have been made regarding the dental treatment to be performed.
I understand that the treatment plan and fees proposed are subject to modification, depending upon
unforeseen or undiagnosed conditions that may be recognized only during the course of treatment.
• I agree to cooperate fully with the recommendations of the doctors and I realize that failure to do
so may result in less than optimum results and compromise the life span of the treatment.
• I also agree to follow the recommendations for home care and the schedule for future check-ups. I
realized that failure to do my part in the maintenance of my oral health will compromise the
success of any dental treatment I may receive.
• I have, to the best of my knowledge, provided the doctor my medical history, on-going and past
medical records, past dental records, family medical history and emergency numbers. I have not
intentionally hidden any medically relevant information. I understand that hiding information
about medical history and communicable diseases is an offence and legal action may be taken
against me .
• I have been told the approximate cost of the treatment (₹. __________________ ).
• I hereby promise to pay the treatment fee on or before _______________________ .

CONSENT: I certify that I understand fully, all the statements mentioned above.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 TREATMENT CONSENT FORM (for Guardian)

I,___________________________________________________, (relation with the patient)

____________________of ____________________________________, hereby give my consent
and authorize Dr. Vaibhav Nepalia, his team and supporting staff to perform all procedures required
for the treatment including but not limited to diagnostic models, radiographs, photographs,
extractions and administration of local anesthesia or other medication. The consent is being signed
on behalf of the patient as:
• he/she is not in the capacity to form a decision pertaining to his/her health
• he/she is a minor.
• I understand that during treatment, it may be necessary to change or add to the planned
procedures because of conditions discovered during the treatment that were not evident during
examination.
• I acknowledge that no guarantees have been made regarding the dental treatment to be performed.
• I understand that the treatment plan and fees proposed are subject to modification, depending upon
unforeseen or undiagnosed conditions that may be recognized only during the course of treatment.
• I agree to cooperate fully with the recommendations of the doctors and I realize that failure to do
so may result in less than optimum results and compromise the life span of the treatment.
• I also agree to follow the recommendations for home care and the schedule for future check-ups. I
realized that failure to do my part in the maintenance of my oral health will compromise the
success of any dental treatment received by the patient.
• I have, to the best of my knowledge, provided the doctor the required medical history, on-going
and past medical records, past dental records, family medical history and emergency numbers. I
have not intentionally hidden any medically relevant information. I understand that hiding
information about medical history and communicable diseases is an offence and legal action may
be taken against me.
• I have been told the approximate cost of the treatment (₹. __________________ ).
• I hereby promise to pay the treatment fee on or before _______________________ .

CONSENT: I certify that I understand fully, all the statements mentioned above.

(Guardian’s Signature) Date:

Guardian’s Full Name: ________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 CONSENT FORM FOR ROOT CANAL TREATMENT

I hereby authorize __________________________________________ (doctor name) and any

associates to perform Root Canal Treatment.
The doctor has explained to me that the purpose of this procedure is to retain teeth that may
otherwise have to be extracted. The doctor has explained to me the treatment and the anticipated
results of the treatment. I understand that there are alternative treatments, and the doctor has
explained the risks and benefits of the alternatives. I also understand that although root canal therapy
has a high success rate, but the doctor has not guaranteed or warranted a perfect result. The doctor
has explained to me that there are certain potential risks in the procedure. These include but are not
limited to:
1. Inability to completely fill the root canal because the canal is calcified or has a unique curvature
(this may require endodontic surgery or extraction of the tooth).
2. Infection that may occur and may continue, requiring further endodontic surgery or extraction.
3. Fracture or breakage of the root or crown portion during or after treatment.
4. Inadvertent breakage of files or instruments within the root canal system that are unable to be
retrieved.
5. Perforation of the tooth or root of the tooth during treatment.
6. Damage to existing fillings, crowns or porcelain veneers.
7. As a result of the injection or use of anesthesia, at times there may be swelling, jaw muscle
tenderness or even a resultant temporary or permanent numbness of the tongue, lips, teeth, jaws
and/or facial tissues.
Unforeseen conditions may arise that require a procedure that is different than set forth above. I
authorize the doctor and any associates to perform such procedures when, in their professional
judgment, the procedures are necessary, after discussing the option with me, and obtaining my verbal
consent (except in emergent circumstances where consent might not be practical to obtain).
I further understand that drugs and anesthetics may cause unanticipated reactions, which might
require medical treatment.
Please do not hesitate to ask the doctor or the staff if you have any questions.

(Signature) Date:

Full Name: _________________________________________________

Address: ___________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 CONSENT FORM FOR COMPOSITE FILLING

I understand that the treatment of my dentition involving the placement of composite resin fillings
will be more aesthetic in appearance than some of the conventional materials.
The doctor has explained to me that the purpose of this procedure is to remove caries and replace lost
tooth structure with filling material. The doctor has explained to me the treatment and the anticipated
results of the treatment. I understand that there are alternative treatments, and the doctor has
explained the risks and benefits of the alternatives. I also understand that although composite
restoration has a high success rate, but the doctor has not guaranteed or warranted a perfect result.
The doctor has explained to me that there are certain potential risks in the procedure. These include
but are not limited to:
1. Sensitivity of teeth
2. Risk of fracture of tooth/filling
3. Necessity for root canal therapy: When fillings are placed or replaced, the preparation of the teeth
often requires the removal of tooth structures adequate to ensure that the diseased &
compromised tooth structure provides sound tooth structure for placement of the restoration. At
times, this may lead to exposure or trauma to underlying pulp tissue. Should the pulp not heal,
root canal treatment or extraction may be required.
4. Aesthetics or appearance: When a composite filling is placed, effort will be made to closely
approximate the appearance of natural tooth color. However, because many factors affect the
shades of teeth, it may not be possible to exactly match the tooth coloration. Also, the shade of
the composite fillings can change over time because of a variety of factors including mouth
fluids, foods, smoking, etc. The dentist has no control over these factors.
5. Breakage, dislodgement or bond failure: Because of extreme masticatory (chewing) pressures or
other traumatic forces, it is possible for composite resin fillings or aesthetic restorations bonded
with composite resins, to be dislodged or fractured. The resin-enamel bond can fail, resulting in
leakage and recurrent decay. The dentist has no control over these factors.
I agree to assume the risks that may occur, even if care and diligence is exercised by my treating
dentist in rendering this treatment.
I voluntarily accept any and all possible risks that may be associated with any phase of this treatment
in hopes of obtaining the desired outcome. By signing this document, I authorize my treating dentist
and /or his/her associates to render any services deemed necessary or advisable in the treatment of
my dental condition, including but not limited to prescribing and administration of any medically
necessary anesthetic agents and/or medications.

(Signature) Date:

Full Name: _________________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 CONSENT FOR CROWN/BRIDGE

I have been advised of and understand that treatment of dental conditions requiring crowns and/or
fixed bridgework, involves certain risks and possible unsuccessful results, including the possibility of
failure. Even when care and diligence is exercised in the treatment of conditions requiring crowns
and bridgework and fabrication of the same, there are no promises or guarantees of anticipated
results or the length of time the crown and/or fixed bridgework will last. I agree to assume the risks
associated with crowns and/or fixed bridgework, which include but are not limited to the following:
1. Reduction of tooth structure: To replace decayed or otherwise traumatized teeth, it is necessary to
modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them.
2. Numbness following use of anesthesia
3. Sensitivity of teeth
4. Crown or bridge abutment (support) teeth may require root canal treatment.
5. Breakage: Crowns and bridges may chip or break. Many factors can contribute to this situation,
including chewing hard materials, change in biting forces, traumatic blows to the mouth, etc. The
laboratory provides warranty on certain crowns and they can be replaced free of charge, however,
I need to pay the cost incurred upon my dentist for removal, impressions and placement of the
prosthesis.
6. Uncomfortable or strange feeling: Crowns and bridges are artificial and therefore feel different
from natural teeth. Most patients become accustomed to this feeling over time.
7. Aesthetics or appearance: Patients will be given the opportunity to observe the appearance of
crowns or bridges in place, prior to final cementation. While satisfactory, this fact is usually
acknowledged by verbal consent by the patient.
8. Longevity of crowns and bridges: Many variables determine how long crowns and bridges can be
expected to last. Among these are some of the factors mentioned in the preceding paragraphs,
including the general health of the patient, oral hygiene, regular dental checkups and diet. As a
result, no guarantees can be made or assumed to be made regarding the longevity of the crowns
or bridges. It is a patient’s responsibility to seek attention from the dentist should any undue or
unexpected problems occur.

By signing this document, I am giving my consent to authorize Dr.

_______________________________ and/or his/her associates to render any treatment necessary
and/or advisable to my dental conditions, including the prescribing and administering of any
medications and/or anesthetics deemed necessary to my treatment.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 CONSENT FOR COSMETIC TREATMENT
(including bleaching, bonding and veneer)

I understand that treatment of my dentition for which I desire cosmetic dental procedures to be
performed, may entail certain risks and possible unsuccessful results, with even the possibility of
failure to achieve the results that may be desired or expected. Even though care and diligence is
exercised in the treatment, there are neither guarantees of anticipated or desired results nor any
assurance of the longevity of the treatment.
I accept and understand those risks, possible unsuccessful results and/or failure associated with but
not limited to the following:
1. Reduction or roughening of tooth structure
2. Sensitivity of teeth: Even though in the majority of the cases (whitening, bleaching, bonding and
veneering teeth) 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
this office for an examination.
3. Chipping, breaking or loosening of the veneer: No matter how well the veneer is placed, this
could occur. Many factors may contribute to this happening, including chewing of hard materials,
changes in occlusal (biting) forces over time, traumatic blows to the mouth, breakdown of the
bonding agents and other conditions over which the doctor has no control.
4. Sensitivity or allergic reactions to whitening, bleaching or bonding agents.
5. Aesthetics/appearance: Every effort possible will be made to match and coordinate both the form
and shade of veneers and/or bonding agents to be cosmetically pleasing to the patient. However,
there are limited number of shades that can be mixed to match natural tooth colour. This makes it
impossible to have the exact shade and/or form to perfectly match your natural dentition.
6. Longevity: It is impossible to identify any specific criteria on the length of time that veneers and
bonding should last or for the lightened appearance of whitened or bleached teeth to maintain the
lightened shades. These time periods may vary depending on many conditions existing from
patient to patient as well as each patient’s individual habits or circumstances.
7. Numbness following use of anesthesia

I have been given the opportunity to ask any and all questions regarding the nature and purpose of
cosmetic dental treatment and have received all answers to my satisfaction. I voluntarily assume any
and all possible risks which may be associated with any phase of this treatment in hopes of obtaining
the desired results. The fee(s) for these services have been explained to me. By signing this form, I
am giving my consent to allow and authorize Dr._____________________________________
and/or his/her associates to render any treatment deemed necessary, desirable and/or advisable to me,
including the administration and/or prescribing of any anesthetics and/or medications.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 CONSENT FOR TOOTH EXTRACTION

Before you give your permission for the removal of teeth, removal of impacted teeth (those that are
“buried” or beneath the gums), or other dental treatment, or for the administration of certain
anesthetics, you should understand that there are certain associated risks.
The common risks include (but not limited to):
1. Drug reactions and side effects.
2. Damage to adjacent teeth or fillings.
3. Post-operative infection.
4. Post-operative bleeding that may require treatment.
5. Possibility of a small fragment of root being left in the jaw when its removal would require
extensive surgery.
6. Delayed healing (dry socket) necessitating frequent post-operative care.
7. Possible involvement of the sinus during removal of upper molars which may require additional
treatment or surgical repair at a later date.
8. Possible involvement of the nerve during the removal of lower molars resulting in temporary or
possible permanent tingling or numbness of the lower lip, chin or tongue on the operated side.
9. Bruising and/or vein inflammation at the site of administration of intravenous medications which
may require further treatment .
10. Other: ________________________________________________________________________

I was given the option of different anesthetic techniques, and I consent for the following anesthetics
to be used:
_______Local anesthesia
_______Local anesthesia with oral pre-medication
_______Local anesthesia with intravenous sedation
_______General anesthesia/hospital operating room

I hereby acknowledge I have completely read the foregoing; have discussed any questions or
concerns which I may have regarding my proposed surgery/dental treatment, and have been given
satisfactory answers.

By signing this document, I authorize Dr. ______________________________________ and/or

his/her associates to render any treatment necessary and/or advisable to my dental conditions,
including the prescribing and administering of any medications and/or anesthetics deemed necessary
to my treatment.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

 REFUSAL OF RECOMMENDED TREATMENT

Patient Name:______________________________________________________________________

Date of Birth:___________________

Name of Consulting Dentist: _________________________________________________________

You have the right and the obligation to make decisions regarding your healthcare. Your dentist can
provide you with the necessary information and advice.
This form will acknowledge your refusal of treatment recommended by your dentist.

Recommended Treatment: __________________________________________________________

I have chosen to refuse this treatment after considering both the recommended and alternative forms
of diagnosis and/or treatment for my condition. Each of these alternative forms of diagnosis or
treatment has its own potential benefits, risks and complications.
I certify that I have read the contents of this form. I understand the possible advantages from
proceeding with the recommended treatment and the possible risks and consequences of refusing the
recommended treatment. I have decided to refuse the treatment recommended by my dentist.
I hereby release my consulting dentist (named above). and his or her employees, associates or
corporation from any liability for any and all injuries and damages I may sustain as a result of my
refusing recommended dental treatment.
I attest that I have had the opportunity to ask questions and all of my questions have been answered
to my satisfaction.

(Patient’s Signature) Date:

Patient’s Full Name: __________________________________________

Address: ___________________________________________________

___________________________________________________________

___________________________________________________________

Phone No.: _________________________________________________

INSTRUCTIONS FOR THE PATIENT UNDERGOING IMPLANT SURGERY

ON THE DAY OF SURGERY

• FIRST HOUR: Bite down gently but firmly on the gauze packs that have been placed over the
surgical areas, making sure they remain in place. Do not change them for the first hour unless the
bleeding is not controlled. The packs may be gently removed after one hour. If active bleeding
persists, place enough new gauze to obtain pressure over the surgical site for another 30 minutes.
The gauze may then be changed as necessary (typically every 30 to 45 minutes). It is best to
moisten the gauze with tap water and loosely fluff for more comfortable positioning.
• EXERCISE CARE: Do not disturb the surgical area today. Do NOT rinse vigorously or probe
the area with any objects. Smoking will retard healing, causing increased discomfort and
increased chance of dry sockets. We strongly discourage smoking during the healing phase.
• ORAL HYGIENE: It is important to keep the mouth clean. You should brush your teeth the night
of surgery, but be gentle around the surgical sites. If there is minimal bleeding, saltwater rinses
may begin 24 hours after surgery (mix 1/2 tablespoon of salt with one glass of water.) Swish
gently and allow the water to drip into the sink. Rinses should be done 2-3 times a day, especially
after eating.
• ACTIVITIES: Activities after surgery should be couch or bed rest for the first day. Bending,
lifting, or strenuous activity will result in increased bleeding, swelling and pain. You should be
careful going from the lying down position to standing. You could get light headed when you
stand up suddenly. If you exercise regularly, be aware that your normal fluid and caloric intake is
reduced. Exercise in the post-operative period may also result in increased bleeding, swelling and
discomfort. Exercise should be avoided for 3-4 days following surgery.
• OOZING: Bleeding will occur after surgery, and it is not uncommon to ooze blood for 24-48
hours after surgery. Keep in mind that oral bleeding represents a little blood and a lot of saliva.
Placing a gauze pack over the area and biting firmly will control bleeding. If oozing is still active,
replace gauze as needed every 30-45 minutes.
• PERSISTENT BLEEDING: Bleeding should never be severe. If so, it usually means that the
packs are being clenched between teeth only and are not exerting pressure on the surgical areas.
Try repositioning the packs. If bleeding persists or begins again sit upright or in a recliner, avoid
physical activity, use ice packs and bite on gauze for 1 hour or on a moistened tea bag for 30
minutes. The tannic acid in the tea leaves helps to promote blood clotting. If bleeding remains
uncontrolled, please call our office.
• SWELLING: Swelling is a normal occurrence after surgery and will not reach its maximum
until 2-3 days after surgery. It can be minimized by using a cold pack, ice bag or a bag of frozen
peas wrapped in a towel and applied firmly to the cheek adjacent to the surgical area. This should
be applied twenty minutes on and twenty minutes off during the first 24 hours after surgery. If
you have been prescribed medicine for the control of swelling, be sure to take it as directed.
• SUGGESTED WAY TO APPLY ICE: Fill two zipper lock bags with crushed ice. Cut a pair of
pantyhose at the thigh and slide both ice bags halfway down the leg (to the knee area). Tie the
ends of the pantyhose on top of the patients head and adjust ice to sides of face over surgical
sites.
• PAIN: Unfortunately most oral surgery is accompanied by some degree of discomfort. You will
usually have a prescription for pain medication. If you take the first pill before the anesthetic has
worn off, you should be able to manage any discomfort better. Some patients find that stronger
pain medicine causes nausea, but if you precede each pain pill with a small amount of food,
chances for nausea will be reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate relief at first, you may supplement each pain pill with
an analgesic such as aspirin or ibuprofen. Some patients may even require two of the pain pills at
one time. Remember that the most severe pain is usually within six hours after the local
anesthetic wears off; after that your need for medicine should lessen. If you find you are taking
large amounts of pain medicine at frequent intervals, please call our office. If you anticipate
needing more prescription medication for the weekend, you must call for a refill during weekday
business hours.
• DIET: Eat any nourishing food that can be taken with comfort. Avoid extremely hot foods. Do
not use a straw for the first few days after surgery. It is sometimes advisable, but not absolutely
required, to confine the first days intake to liquids or pureed foods (soups, puddings, yogurt, milk
shakes, etc.) Avoid chewing food until tongue sensation has returned. It is best to avoid foods
like rice, nuts, sunflower seeds, popcorn, etc., which may get lodged in the surgical areas. Over
the next several days you may gradually progress to solid foods. It is important not to skip meals!
If you take nourishment regularly you will feel better, gain strength, have less discomfort and
heal faster. If you are a diabetic, maintain your normal eating habits or follow instructions given
by your doctor.
• NAUSEA: Nausea and vomiting can occur as a result of swallowed blood, discomfort,
anesthesia or pain medicines. Post-operative nausea is usually self-limiting and sipping on flat
cola or ginger ale often helps. Soda crackers also may be used. If nausea persists, stop taking the
pain medicine and substitute an over the counter pain medicine for the next dose. If nausea
persists call our office.
 INSTRUCTIONS FOR THE SECOND AND THIRD DAYS

• MOUTH RINSES: Keeping your mouth clean after surgery is essential. Use 1/4 teaspoon of
salt dissolved in an one glass of warm water and gently rinse with portions of the solution,
taking five minutes to use the entire glassful. Repeat as often as you like, but at least two or
three times daily.
• BRUSHING: Begin your normal oral hygiene routine as soon as possible after surgery.
Soreness and swelling may not permit vigorous brushing, but it is extremely important to clean
your teeth within the bounds of comfort. Maintaining a clean environment adjacent to the
healing surgical wounds is required for optimum and speedy healing.
• HEALING: Normal healing after placement of dental implants should be as follows: The first
two days after surery are generally the most uncomfortable and there is usually some swelling.
On the third day you should be more comfortable and, although still swollen, can usually
begin a more substantial diet. The remainder of the post-operative course should be gradual,
steady improvement. If you don’t see continued improvement, please call our clinic.
• DISCOLORATION OR BRUISING: The development of black, blue, green or yellow
discoloration is due to bruising beneath the tissues. This is a normal post-operative occurrence
that might appear 2-3 days after surgery. Beginning 36 hours after the surgery, moist heat
applied to the area may speed up resolution of the discoloration.
• SHARP EDGES: If you feel something hard or sharp edges in the surgical areas, it is likely
you are feeling the bony walls which once supported the extracted teeth. Occasionally small
slivers of bone may work themselves out during the following week or so. If they cause
concern or discomfort, please call the office.
• DRY LIPS: If the corners of your mouth are stretched they may dry out and crack. Keep your
lips moist with an ointment such as Vaseline.
• SORE THROAT: This is not uncommon after oral surgery. The muscles get swollen and this
may make swallowing painful. This should go away on its own in 2-3 days.
• STIFF JAW MUSCLES: This may cause a limitation in opening the mouth wide for a few
days after surgery. This is a normal post-operative event that usually resolves during the week
after surgery. Stretching these muscles may help to speed up resolution of this problem.

Your case is individual. No two mouths are alike.

Do not accept well-intended advice from friends.
Discuss your problem with us for the best advice!
 Instructions to patients undergoing ORTHODONTIC treatment

1. FOOD
a. In general, AVOID eating anything hard or sticky. Such foods can loosen bands or break
brackets causing delay in your treatment.
b. CUT your food into small pieces before chewing. Chew slowly and carefully.
c. AVOID biting into hard food or fruits (like apple, pear, guava etc.). You can still have
your favorite fruits, but CUT them into small pieces with a knife first and chew slowly.
d. AVOID sweets, chocolates, cakes, pastries, cheese items, burger, pizza, sugarcane,
toffees, rolls, kachori, samosa, tandoori items, and in general fast food items.

2. ORAL HYGIENE
a. BRUSH at least twice a day.
b. RINSE with the mouthwash recommended by your orthodontist.
c. NEVER use toothpicks or pins to dislodge food particles stuck in brackets or teeth.
Contact us.
d. NEVER put pen, pencil, finger or thumb in your mouth.
e. DON’T bite your nails.

3. SPORTS
a. You can play and participate in outdoor sport activities ONLY while wearing a
protective headgear(helmet).

4. EMERGENCIES: In case you find your bracket or band has come loose, inform us
IMMEDIATELY and schedule an appointment.

5. APPOINTMENTS
Our doctors are very particular in maintaining scheduled appointments. In case you are unable
to come on the time allotted due to some emergency, KINDLY call us at least a day in
advance and reschedule. This will ensure that your time slot will be used for other patients. In
case you fail to inform us, a charge of Rs.500/- will be added to your final billing for doctor’s
time.
 POSSIBLE PROBLEMS DURING ORTHODONTIC TREATMENT

DECALCIFICATION, DECAY, OR GUM DISEASE: These problems may occur if the patient does not
cooperate with proper brushing and flossing.
PRE-EXISTING, NON-VITAL, DEVITALIZATION, TRAUMATIZED TEETH: Sometimes a tooth
may have been traumatized by a blow or have large fillings that cause damage to the nerve. It is possible
for the nerve inside a tooth to die during treatment thus requiring a root canal on the affected tooth.
TEMPORO-MANDIBULAR JOINT PAIN: Orthodontic treatment may help remove dental causes of
TMJ, but not non-dental causes. Some patients may develop jaw joint noises, discomfort and facial pain
related to the jaw during or after treatment. The current belief is that these problems are caused more by
habitual grinding of the teeth rather than the way in which the teeth bite. If such a problem arises,
treatment by another specialist may be required.
DISCOMFORT: As the mouth is sensitive, you may expect some discomfort due to adjustment and
application of appliances. Nonprescription pain medication may be used to address this adjustment pain.
ORAL SURGERY/EXTRACTIONS: To achieve optimal results, oral surgery or tooth extraction may be
necessary together with orthodontic treatment, especially to correct jaw imbalances. Third molars
(wisdom teeth) may develop and change alignment. Your dentist and orthodontist may recommend that
your third molars be removed.
OCCLUSAL ADJUSTMENT: You can expect minimal imperfections in the way your teeth meet
following the end of treatment. An occlusal equilibration procedure may be necessary, which is a
grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of
enamel in between the teeth, thereby “flattening” surfaces in order to reduce the possibility of a relapse.
ALLERGIES: Allergies to medicine and orthodontic materials may occur during treatment. This may be
avoided if disclosed to us. If they are unknown to us, it is impossible to predict reactions.
TREATMENT TIME: The total time for treatment can be delayed beyond our estimate. Abnormal facial
growth, poor elastic wear, or headgear cooperation, broken appliances and missed appointments are all
important factors that could lengthen treatment time and affect the quality of the result. These
circumstances are not in control of the doctor.
INJURY FROM APPLIANCES AND HEADGEAR: Some orthodontic appliances like Headgear or
facemask, if improperly handled, may cause injury. Orthodontic appliances may be accidentally
swallowed or aspirated, or may irritate or damage oral tissue. Contact sports and similar activities should
not be performed while headgear and other extra-oral appliances are worn.
RELAPSE: We intend to obtain the best result possible. Some orthodontic problems, however, tend to
relapse a small degree due to growth, occlusal adjustments, changes in food pattern or other habits.
Careful cooperation during the retention phase of treatment will keep this relapse to a minimum.
ADDITIONAL TREATMENT: Unforeseen circumstances (such gum disease) may cause us to
recommend additional treatment not previously discussed. If this occurs, we will carefully explain the
reasons for a change in the treatment plan and any extra fees before proceeding.
TERMINATION OF TREATMENT: It is understood that treatment can be terminated for failure to
cooperate, missing appointments, not wearing appliances, excessive breakage, failure to keep financial
commitments, relocation, personal conflicts or for any other reason the orthodontist feels necessary.
CONSENT TO USE RECORDS: I hereby give my permission for the use of orthodontic records,
including photographs for purposes of professional consultations, research, education or publication in
professional journals.
I have read the above and have had an opportunity to discuss this information with my doctor. All
questions have been answered to my satisfaction. I authorize Dr. Vaibhav Nepalia and his team to
perform the necessary orthodontic treatment.

(Patient’s Signature) Date:

Patient’s Full Name: ______________________________________________________________________

Address: ________________________________________________________________________________
 PATIENT’S RIGHTS

As a patient at Dental SolutionS, it’s your right to:

1. Know in detail about the disease you have & its causes.
2. Know the possible treatment options available for you.
3. Know about possible outcomes/ side-effects of the treatment.
4. Chose the treatment suiting your need and budget.
5. Consent to or refuse a treatment BEFORE we begin.
6. Privacy. Your records are confidential as per the law.

PATIENT’S DUTIES

As a patient at Dental SolutionS, please understand your duties:

1. Be truthful and express your concerns clearly to the doctor.
2. Provide a complete medical history, including information about past illnesses,
medications, hospitalizations, family history of illness, and other matters relating to
present health. Dental SolutionS will keep all such records confidential as per the law.
3. Once consent is made about your therapy, co-operate with your doctor during the
treatment phase.
4. Take the prescribed medications as directed. Do not stop or continue medication without
doctor’s advice.
5. Stick to the payment schedule explained to you. In case of delayed / missed payments, we
reserve the right to reschedule your appointment or stop the treatment.

If you have any questions about your treatment at any time, please feel free to contact us at
75971-63111 / 87693-83636