Consent Form

Do you feel pain in any of your teeth?*

Describe the pain in your teeth

Do you have any sores or lumps in or near your mouth?*

Describe the sores or lumps

Do you currently have any head, neck or jaw injuries?*

Describe your head, neck or jaw injuries

Do you currently experience jaw: clicking, pain, difficulty opening and/or closing or difficulty chewing?*

Please describe

Do you have untreated periodontal disease?*

Please describe

Do you have any known allergies to any dental materials?*

Please describe your allergies

Mark all that apply about your dental history

I am currently taking on of the following medications (oral biphosphonates)l Fosamax, Actonel, didronel, Boniva, Aredia, Zometa
I have current acute corticosteroid or immuno supressants
I have had a bone marrow transplant or treatment of hemotol within the past 2 years

Consent To Treatment

Full Name (using English characters)*

Name (Kanji or Hiragana)*

Email*

Consent to Treatment*

I have read the consent information, filled out the form truthfully, and I consent to treatment*