525 Tyler Road, Suite E
St. Charles, Illinois 60174
(630) 377-4677
Diagnosis: You have been diagnosed with inadequate tooth length. Your dentist has determined that a crown lengthening procedure should be performed prior to crown placement to insure a proper fit or for esthetics. This procedure is required due to one or more of the following: tooth fracture below the gum line, excessive decay, root decay, or excessive gum tissue.
Recommended Treatment: In order to treat this condition, my periodontist has recommended that a biopsy be performed. The oral biopsy will involve the following steps:
Expected Benefits:The purpose of this procedure is to obtain a sample of oral tissue for further examination and analysis, and provide an accurate diagnosis of my oral health condition.
Risks of Biopsy: I have been informed that the oral biopsy procedure carries the following risks:
I hereby certify that I clearly comprehend the nature, purpose, benefits, risks and alternatives to (including no treatment), the proposed procedure(s). I have been given the opportunity to ask questions and they have been answered to my complete satisfaction.
I authorize photos, slides, x-rays or any other viewing of my care and treatment during of after its completion to be used for advancement of dentistry and reimbursement purposes. However, my identity will not be revealed to the general public without my permission.
I have read and understand the above.