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Consent for Final Cementation of Gold crowns

The nature and type of material used in my crowns, bridges and/or veneers has been explained to me. By signing below, I acknowledge and authorize the material discussed to be used in my mouth. I have been given the opportunity to view my crowns, bridges and/or veneers as processed, either on models or placed in my mouth prior to final cementation.

I approve the color, shape, feel and overall appearance of the porcelain. I understand that once the Gold is cemented in my mouth, the factors of color, shape, feel and overall appearance cannot be changed without additional and possibly significant time being taken and fees assessed. I further understand that removing cemented Gold may create the risk of injury or breakage to the underlying teeth and will destroy the Gold, requiring a remake. This is not a permanent restoration or advised as a permanent restoration due to possible decay under crowns due to leakage over time. I further understand that if I authorize cementation and later decide I do not like the restorations, any replacement(s) of the cemented restorations will be at full cost.

I understand that all deposits, partial, and full payments are NON-REFUNDABLE

By signing this Consent for Final Cementation, I give Build A Smile, my consent for final cementation, acknowledge my approval of the appearance and authorize use of the discussed material.

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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