Patient Name :* First Name : Middle Name : Last Name : Your birthday :* MM slash DD slash YYYY Telephone:*Email address :* I,__________________________ , hereby authorize, Please SelectDentistHygienistOtherDoctor's Name to perform local anesthetic injections(s). I understand, as it has been explained to me that there are some risks in the administration of local anesthetics. Most risks are related to the position of the nerves under the tissue at the site of the injections, which cannot be determined prior to the administration of the anesthetic agent. Although, the risk seldom occur they might include loss of, or distributed sensation of the tongue and lip on the side of the injection. If this occurs it is often temporary, and normal sensation returns in several days. However, in very rare cases the loss of sensation may extend for a longer period and may become permanent. In addition, injecting in a foreign substance into the body such as an anesthetic agent may result in allergic reaction. Allergic reactions to these agents are rare, but may take place. I further understand that individual reactions to treatment cannot be predicted. If I experience any unanticipated reactions following injection(s), I agree to report them to the office immediately. I have been told that the success of my dental treatment depends upon my cooperation in keeping scheduled appointments, following home care instructions, including hygiene and dietary instructions, taking prescribed medication and reporting to the office any change in my health status. I acknowledge that no guarantees or assurance have been given by anyone as to the results that may be obtained. I have discussed all of the above with the doctor, and have had all my questions answered. Signature*Date MM slash DD slash YYYY
