The Loving Dentist - After Hours Care

Final Cementation Consent


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 porcelain 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 porcelain may create the risk of injury or breakage to the
underlying teeth and will destroy the porcelain, requiring a remake. 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.
By signing this Consent for Final Cementation I give the office named above my
consent for final cementation, acknowledge my approval of the appearance and
authorize use of the discussed material.

Signed on: 

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Signed by The Loving Dentist After Hours Care
Signed On: April 4, 2018

The Loving Dentist - After Hours Care http://thelovingdentalclinic.com
Signature Certificate
Document name: Final Cementation Consent
Unique Document ID: 78c3a73600022e3fa2a406e81126779f6022553b
Timestamp Audit
April 4, 2018 1:09 pm ESTFinal Cementation Consent Uploaded by The Loving Walk-In Dental Clinic of Orlando - orlando.dentalclinic@gmail.com IP 50.24.40.12