SECTIONEDITOR
ormed
consent
treatment
George A. Murrell, MS, DIX,a and Gerald University of Southern California, Los Angeles, Calif.
report
A. Sheppard,
LLBb
A brief history of informed consent and introduction of the “Informed Consent Treatment Report” (ICTR) is presented. The ICTR is a document developed in 1984 that combines the requirements of informed consent and the elements of good treatment planning and presentation to achieve improved patient and practice management. An outline of the parts and sections of the ICTR is included as a guide for preparing an informed consent and treatment planning document. (J PROSTHET DENT 1992;68:970-3.)
llowing a brief history of informed consent, the conce the Informed Consent Treatment Report (ICTR) is presented. This document combines the needs of informed consent and thorough treatment planning for improved management in cases requiring long or complex treatment. The purpose of this report is to provide an outline for practitioners who wish to develop their own-and possibly more effective-informed consent documentation.
HISTORY The doctrine of patient consent is not a recent legal phenomenon. In 1649 a law passed in the Massachusetts Bay Colony decreed that no physicians, chirurgeons, midwives, or others shall exercise any act without consent of the patient.l> 2 The earliest common law malpractice lawsuit involving consent occurred in 1767 when the English court ruled against a surgeon and an apothecary for failure to inform the patient of the proposed treatment before it was performed. The doctrine of informed consent emerged slowly until the period from 1905 to 1914. During that time, several court decisions were made that significantly influenced formulation of the basic features of American informed consent law.l, 3
ONSEMT From a legal view, there are two kinds of consent, plain and informed. Plain consent relates to battery (unlawful touching). If a practitioner proceeds with treatment without the patient’s plain consent, that patient could, in most states, bring suit for battery or unwarranted trespass regardless of the success of the treatment. Informed consent refers to informing or disclosing to the patient the na-
Presented before the American Meeting, Santa Barbara, Calif. “Clinical Professor of Restorative bInstructor, School of Law. 1011/41381 970
Academy Dentistry,
of Esthetic School
Dentistry of Dentistry.
ture and treatment of his or her dental problem in a comprehensive manner. Legal requirements and interpretations of Informed Consent Doctrine vary with each state and many countries, but the minimum considerations with which the patient must be presented and understand are best reconciled as (1) patient reasons for treatment, (2) diagnosis, (3) prognosis, (4) nature of care and treatment, (5) alternatives, (6) risks, (7) expectancies of success, and (8) possible results if no care or treatment is undertaken. Within this disclosure, the dentist must also be concerned with the amount of information that the patient must be told and the scope of information that is necessary to satisfy the needs of informed consent. Failure by the practitioner to obtain informed consent would constitute negligence, which, in dentistry, is synonymous with “malpractice”.4 There are also two standards used in American courts today. The first is the professional standards test, based on providing the same level of information as other dentists in the area provide. The second is the prudent patient or material risk test, based on the information a prudent patient requires to decide whether to undergo the proposed treatment.4, 5
THE
PROBLEM
Many dentists could become frustrated attempting to apply the doctrine of informed consent, because it is complex, controversial, and it varies from state to state as to the law, its interpretation, and its application. In 1984, the author (GAM) developed the Informed Consent Treatment Report (ICTR) because many of the available standard consent forms at that time seemed impersonal, inadequate, or otherwise inappropriate. The ICTR has been used successfully since 1984, and it subsequently has been continuously revised and modified when necessary to remain current.
ICTR
FORMAT
The ICTR consists of two parts, each with the number of sections necessary to fully inform the patient about the DECEMBER1992
VOLUME68
NUMBER6
INFORMED
CONSENT
TREATMENT
REPORT
nature of his or her dental problem. Part I contains information regarding the patient’s chief complaint, diagnosis, treatment recommendations, and office policy. Part I concludes with a signature page in which the patient confirms his or her understanding of the dental recommendations and acceptance of the office policy. Part II includes the office financial policy and a section on treatment sequencing and cost estimates. The total estimated fee, treatment duration, and acceptance signature page conclude part II. The preparation of an ICTR includes specific patient information, such as chief complaint, histories, patient desires, findings, and recommended treatments and fees. This information is combined with the general dental information that is stored in the word processing data bank. DISCUSSION Legal informed consent can be attained by a well-documented verbal communication and a formal, printed document, particularly if the consultation remarks are adequate and documented in the doctor’s handwriting. The ICTR is not an attempt to set a precedent for lengthy, written documents, but instead to suggest a protocol to satisfy most informed consent needs in almost any area of dentistry where the treatment is long and complex or patient management might otherwise be difficult. The intention of the ICTR is twofold: to satisfy the legal requirements of informed consent by documenting and comprehensively informing the patient about his or her dental problems, and second, to present information to the patient in a positive, acceptable way so that it becomes a patient management tool. The ICTR should be well organized and properly written in simple or lay language whenever possible. If technical language is necessary or the if treatment is complex, a glossary of terms, graphics, or other illustrations should be included. Most important, the dentist should personally review the ICTR with the patient in detail to be certain that he or she fully understands the circumstances of the treatment, the terminology, fees, and policies of the office. For informed consent to be legally effective, the patient must be informed and understand the information. For the treatment report to be effective, patients should be made aware of the benefits as well as the risks; otherwise they might not submit to the possible discomfort or cost of the proposed dental treatment. The ICTR must be properly presented; it is never mailed or given to the patient without the dentist first reviewing it in person. The dentist first reviews the ICTR with the patient. When it is fully understood and all required signatures are obtained, the original document is given to the patient for the patient’s records; a copy is retained in the patient’s chart, and an additional copy is sent to each cotreating specialist to facilitate interoffice communications. A copy of the “Treatment Sequence and Cost Estimate” section may be reduced in size and placed in the patient’s chart as a readily available reference for monitoring treatment progress, appointments, fees, and interoffice communications. TUE
JOURNAL
OF PROSTHETIC
DENTISTRY
It should be noted that section headings illustrated in the ICTR example that follows vary according to the type and complexity of treatment and the details desired by the doctor. Examples of the text for the first sections have been omitted because of the wide variance in both specific and general information and the limitation of space. “The Treatment Sequence and Cost Estimate” section of part II is a good example of an involved treatment. The text has been included here to illustrate how the ICTR can function to facilitate thorough pretreatment planning, interoffice communications and minimize interruptions from patient questions during the clinical procedures. Specific information sections (underlined), are unique to each patient and must be written for each individual patient. General information sections (not underlined) usually remain unchanged and can be used for many patients with similar treatment conditions. General information is stored in the word processing data bank and is readily available for compiling an ICTR. INFORMED CONSENT REPORT-PART I Introduction
TREATMENT
“The purpose of this report is to inform you . . . .. . . . .. . .. . . . .. . .. . . . Once you fully understand your dental situation, you will be asked to provide the appropriate signatures on the endorsement pages.”
Specific
sections
Patient complaint-“You first presented on __ - - _ stat1, ing Medical history-Only that which pertains to this treatment Dental history-Only that which pertains to this treatment Synopsis-Helpful if ICTR is long or complex Examination-“Clinical and x-ray findings re31 vealed Consultation-Requires findings from referrals Recommended treatment-Benefits, risks, be positive, no promises Treatment alternatives-Options, possible effect of nontreatment
General
sections
Implants-General description of implants, types, benefits, risks Dentures-Description of adapting to change, esthetics, function Fixed partial denture-Reasons for crowns, bridges, benefits, risks Ofice Policy-Policy re: photographs, video, appointments, etc. Warranty-Describe adjustment periods and warranty policy, if any
Patient
acceptance
“I understand viewed in this
the recommendations report
detailed
in my chart
and re-
1,
Endorsement “Your endorsement of this Report, Part I, indicates These stipulations are requested of all prospective least one other opinion from an “interested” party
patients so at will be sought 971
MURRELL
by you and that procedures will not be entered into without thorough deliberation on your part. If you have any questions concerning the recommended treatment, alternatives, benefits, procedures, limitations, possible complications or any other information relative to your proposed treatment, please ask.”
Patient signature
Date
Parent or legal guardian (if under 18)
Spouse or interested co-signer (optional)
Witness (professional staff member)
INFORMED CONSENT REPORT-PART II Financial
Date
Date
Date
TREATMENT
Please note to include a statement of your office financial policy here. “Dental fees in this office are based on the nature and complexity of the dental procedure. Once the schedule of treatment is . . .. .. . .. . .. . .. . . . .3,
Treatment
sequence
and cost estimate
1. Finalize prosthodontic diagnosis, consultations, review patient information, consent, financial arrangements, appointment scheduling, and coordinating specialty referrals. Dr. George Murrell; Fee: $ 2. Presurgical X-rays, CT scans, conferences between Dr. to finalize surgical-prosthodontic treatment options and patient approval Doctor -;Fee: Separate Dr. George Murrell; Fee: Included above 3. Extract teeth #s 5,621, and 26. Provisionalize from #s 3 to ‘7, and 25 to 27, but not the lower left arch. Dr. George Murrell; Fee: $ 4. Periodontal and endodontic evaluation and treatment as described. Maintain provisionalization as described above. (Note that no provision has been made for additional areas of temporary provisionalization treatment. If this becomes necessary during periodontal treatment, additional fees will be required.) Periodontics
Doctor
;Fee: Separate
Endodontics
Doctor
AND
SHEPPARD
fixed bridges/splints that extend from #3 to #7, #7 to #14, #22 to #27, and #27 to #30, #5 and #6 will initially be a metal resin temporary provisional prior to first implant surgery through second implant surgery. Then it will be removed and remade with attachment cylinders and resin veneers to function as gradual loading provisionals for the following 4 to 6 months. After a prefinalization review, #5 and 6 gradual-loading provisionals will be removed and reprocessed to replace resin veneers with porcelain for final placement. No provisionals are planned for #20 and 21 until the gradual loading provisional stage following second surgery. The procedures for carrying #20 and 21 through to finalization are the same as with #5 and 6. Dr. George Murrell; Fee: $ Note that this fee includes 5 above up to second surgery. Additional following procedures described in 5 will be charged out several months later as they are done. 6. Make impressions, develop the esthetic and functional tooth position for #s 5, 6, 20, 21, and fabricate upper and lower surgical stents for the surgeon. Dr. George Murrell; Fee: $ 7. First phase surgery. Surgically place Branemark type implant fixtures in approximate tooth positions: 5, 6,20, 21. Surgically perform hard and soft tissue plasty as necessary. Doctor ; Fee: Separate 8. Refit the provisional #5-#6 following first surgery, maintain postsurgical provisionalization and monitor tissue healing for 4 to 8 months. Dr. George Murrell; Fee: Included in #5 above. 9. Second phase surgery. Surgically attach transepithelial abutments to the osseointegrated implant fixtures. Surgically perform hard and soft tissue plasty as necessary. Doctor ; Fee: Separate 10. Fabricate osseointegrated implant metal superstructure frames with gold cylinder attachments to fit the new upper and lower abutments at #5 to #6 and #20 to #21. Maintain gradual loading and healing provisionalization for 4 to 6 months. Dr. George Murrell; Fee: $ 11. Conduct prefinalization review conferences with the patient and the surgeon to confirm the appropriate time to commence finalization and any desired modifications to be incorporated into the final prostheses. Remove upper and lower gradual loading prostheses, remove resin veneers, and replace with ceramic porcelain, place the final upper and lower implant prostheses, #5 to #6 and #20 to #21 into position. Dr. George Murrell; Fee: $ The total estimated fee for the recommended prosthodontic services described in this report is $ This applies to services rendered in this office only, it does not reflect any alternative treatment suggestions and does not include surgical or any other referred services. The estimated treatment time is 24 to 30 months depending on the duration of periodontics, endodontics, and the type of prosthodontic services being rendered. Except for major treatment changes or additional time or procedure requirements described earlier in this report, these fees will remain in effect if treatment commences by April, 1991 and is completed by October, 1993.
;Fee: Separate
Prosthodontics
Dr. George Murrell; Fee: Included above 5. Upon completion of active periodontal and endodontic treatment, perform all preparations, impressions, and try-ins necessary to fabricate and cement the following fixed prosthodontic restorations: Three (3) upper and two (2) lower porcelain-metal 972
Patient signature
Date
Witness Date DECEMBER
1992
VOLUME
68
NUMBER
6
INFORMEDCONSENTTREATMENTREPORT
5. Academy of Denture Prosthetics. Principles, concepts, pr0sthetics.J PROSTHETDENT 1989;61:88-109.
REFERENCES 1. Smith TJ. Informed consent doctrine. Y Law Eth Dent 1988;1:159-69. 2. Strauss MB. Familiar medical quotations. Boston: Little, Brown & Co, 1968;157-8. 3. Prosser W. Cases and materials in torts. St Paul, Minx West Publishing Co. 19'77;165-6. 4. Ebersold LA. Malpractice: risk management for dentists. Tulsa: PennWell Books, 1986;64.
Bound
volumes
and practices
in
Reprint requests to: GEORGE A.MuRRELL,DDS ~~O~SEPULVEDABLVD.,SUITE 200 MANHATTANBEACH,CA 90266
available
to subscribers
Bound volumes of THE JOURNAL OF PROSTHETIC DENTISTRY are available to subscribers (only) for the 1992 issues from the publisher at a cost of $55.00 ($68.00 international) for Vol. 67 (January-June) and Vol. 68 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 65 and 66 are also available. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA, phone (800) 325-4177, ext. 4351, or (314)453-4351. Subscriptions must be in force to qualify. in place of a regular JOURNAL subscription.
THEJOURNALOF
PROSTHETIC
DENTISTRY
Bound
volumes
are not available
973
ormed
consent
treatment
George A. Murrell, MS, DIX,a and Gerald University of Southern California, Los Angeles, Calif.
report
A. Sheppard,
LLBb
A brief history of informed consent and introduction of the “Informed Consent Treatment Report” (ICTR) is presented. The ICTR is a document developed in 1984 that combines the requirements of informed consent and the elements of good treatment planning and presentation to achieve improved patient and practice management. An outline of the parts and sections of the ICTR is included as a guide for preparing an informed consent and treatment planning document. (J PROSTHET DENT 1992;68:970-3.)
llowing a brief history of informed consent, the conce the Informed Consent Treatment Report (ICTR) is presented. This document combines the needs of informed consent and thorough treatment planning for improved management in cases requiring long or complex treatment. The purpose of this report is to provide an outline for practitioners who wish to develop their own-and possibly more effective-informed consent documentation.
HISTORY The doctrine of patient consent is not a recent legal phenomenon. In 1649 a law passed in the Massachusetts Bay Colony decreed that no physicians, chirurgeons, midwives, or others shall exercise any act without consent of the patient.l> 2 The earliest common law malpractice lawsuit involving consent occurred in 1767 when the English court ruled against a surgeon and an apothecary for failure to inform the patient of the proposed treatment before it was performed. The doctrine of informed consent emerged slowly until the period from 1905 to 1914. During that time, several court decisions were made that significantly influenced formulation of the basic features of American informed consent law.l, 3
ONSEMT From a legal view, there are two kinds of consent, plain and informed. Plain consent relates to battery (unlawful touching). If a practitioner proceeds with treatment without the patient’s plain consent, that patient could, in most states, bring suit for battery or unwarranted trespass regardless of the success of the treatment. Informed consent refers to informing or disclosing to the patient the na-
Presented before the American Meeting, Santa Barbara, Calif. “Clinical Professor of Restorative bInstructor, School of Law. 1011/41381 970
Academy Dentistry,
of Esthetic School
Dentistry of Dentistry.
ture and treatment of his or her dental problem in a comprehensive manner. Legal requirements and interpretations of Informed Consent Doctrine vary with each state and many countries, but the minimum considerations with which the patient must be presented and understand are best reconciled as (1) patient reasons for treatment, (2) diagnosis, (3) prognosis, (4) nature of care and treatment, (5) alternatives, (6) risks, (7) expectancies of success, and (8) possible results if no care or treatment is undertaken. Within this disclosure, the dentist must also be concerned with the amount of information that the patient must be told and the scope of information that is necessary to satisfy the needs of informed consent. Failure by the practitioner to obtain informed consent would constitute negligence, which, in dentistry, is synonymous with “malpractice”.4 There are also two standards used in American courts today. The first is the professional standards test, based on providing the same level of information as other dentists in the area provide. The second is the prudent patient or material risk test, based on the information a prudent patient requires to decide whether to undergo the proposed treatment.4, 5
THE
PROBLEM
Many dentists could become frustrated attempting to apply the doctrine of informed consent, because it is complex, controversial, and it varies from state to state as to the law, its interpretation, and its application. In 1984, the author (GAM) developed the Informed Consent Treatment Report (ICTR) because many of the available standard consent forms at that time seemed impersonal, inadequate, or otherwise inappropriate. The ICTR has been used successfully since 1984, and it subsequently has been continuously revised and modified when necessary to remain current.
ICTR
FORMAT
The ICTR consists of two parts, each with the number of sections necessary to fully inform the patient about the DECEMBER1992
VOLUME68
NUMBER6
INFORMED
CONSENT
TREATMENT
REPORT
nature of his or her dental problem. Part I contains information regarding the patient’s chief complaint, diagnosis, treatment recommendations, and office policy. Part I concludes with a signature page in which the patient confirms his or her understanding of the dental recommendations and acceptance of the office policy. Part II includes the office financial policy and a section on treatment sequencing and cost estimates. The total estimated fee, treatment duration, and acceptance signature page conclude part II. The preparation of an ICTR includes specific patient information, such as chief complaint, histories, patient desires, findings, and recommended treatments and fees. This information is combined with the general dental information that is stored in the word processing data bank. DISCUSSION Legal informed consent can be attained by a well-documented verbal communication and a formal, printed document, particularly if the consultation remarks are adequate and documented in the doctor’s handwriting. The ICTR is not an attempt to set a precedent for lengthy, written documents, but instead to suggest a protocol to satisfy most informed consent needs in almost any area of dentistry where the treatment is long and complex or patient management might otherwise be difficult. The intention of the ICTR is twofold: to satisfy the legal requirements of informed consent by documenting and comprehensively informing the patient about his or her dental problems, and second, to present information to the patient in a positive, acceptable way so that it becomes a patient management tool. The ICTR should be well organized and properly written in simple or lay language whenever possible. If technical language is necessary or the if treatment is complex, a glossary of terms, graphics, or other illustrations should be included. Most important, the dentist should personally review the ICTR with the patient in detail to be certain that he or she fully understands the circumstances of the treatment, the terminology, fees, and policies of the office. For informed consent to be legally effective, the patient must be informed and understand the information. For the treatment report to be effective, patients should be made aware of the benefits as well as the risks; otherwise they might not submit to the possible discomfort or cost of the proposed dental treatment. The ICTR must be properly presented; it is never mailed or given to the patient without the dentist first reviewing it in person. The dentist first reviews the ICTR with the patient. When it is fully understood and all required signatures are obtained, the original document is given to the patient for the patient’s records; a copy is retained in the patient’s chart, and an additional copy is sent to each cotreating specialist to facilitate interoffice communications. A copy of the “Treatment Sequence and Cost Estimate” section may be reduced in size and placed in the patient’s chart as a readily available reference for monitoring treatment progress, appointments, fees, and interoffice communications. TUE
JOURNAL
OF PROSTHETIC
DENTISTRY
It should be noted that section headings illustrated in the ICTR example that follows vary according to the type and complexity of treatment and the details desired by the doctor. Examples of the text for the first sections have been omitted because of the wide variance in both specific and general information and the limitation of space. “The Treatment Sequence and Cost Estimate” section of part II is a good example of an involved treatment. The text has been included here to illustrate how the ICTR can function to facilitate thorough pretreatment planning, interoffice communications and minimize interruptions from patient questions during the clinical procedures. Specific information sections (underlined), are unique to each patient and must be written for each individual patient. General information sections (not underlined) usually remain unchanged and can be used for many patients with similar treatment conditions. General information is stored in the word processing data bank and is readily available for compiling an ICTR. INFORMED CONSENT REPORT-PART I Introduction
TREATMENT
“The purpose of this report is to inform you . . . .. . . . .. . .. . . . .. . .. . . . Once you fully understand your dental situation, you will be asked to provide the appropriate signatures on the endorsement pages.”
Specific
sections
Patient complaint-“You first presented on __ - - _ stat1, ing Medical history-Only that which pertains to this treatment Dental history-Only that which pertains to this treatment Synopsis-Helpful if ICTR is long or complex Examination-“Clinical and x-ray findings re31 vealed Consultation-Requires findings from referrals Recommended treatment-Benefits, risks, be positive, no promises Treatment alternatives-Options, possible effect of nontreatment
General
sections
Implants-General description of implants, types, benefits, risks Dentures-Description of adapting to change, esthetics, function Fixed partial denture-Reasons for crowns, bridges, benefits, risks Ofice Policy-Policy re: photographs, video, appointments, etc. Warranty-Describe adjustment periods and warranty policy, if any
Patient
acceptance
“I understand viewed in this
the recommendations report
detailed
in my chart
and re-
1,
Endorsement “Your endorsement of this Report, Part I, indicates These stipulations are requested of all prospective least one other opinion from an “interested” party
patients so at will be sought 971
MURRELL
by you and that procedures will not be entered into without thorough deliberation on your part. If you have any questions concerning the recommended treatment, alternatives, benefits, procedures, limitations, possible complications or any other information relative to your proposed treatment, please ask.”
Patient signature
Date
Parent or legal guardian (if under 18)
Spouse or interested co-signer (optional)
Witness (professional staff member)
INFORMED CONSENT REPORT-PART II Financial
Date
Date
Date
TREATMENT
Please note to include a statement of your office financial policy here. “Dental fees in this office are based on the nature and complexity of the dental procedure. Once the schedule of treatment is . . .. .. . .. . .. . .. . . . .3,
Treatment
sequence
and cost estimate
1. Finalize prosthodontic diagnosis, consultations, review patient information, consent, financial arrangements, appointment scheduling, and coordinating specialty referrals. Dr. George Murrell; Fee: $ 2. Presurgical X-rays, CT scans, conferences between Dr. to finalize surgical-prosthodontic treatment options and patient approval Doctor -;Fee: Separate Dr. George Murrell; Fee: Included above 3. Extract teeth #s 5,621, and 26. Provisionalize from #s 3 to ‘7, and 25 to 27, but not the lower left arch. Dr. George Murrell; Fee: $ 4. Periodontal and endodontic evaluation and treatment as described. Maintain provisionalization as described above. (Note that no provision has been made for additional areas of temporary provisionalization treatment. If this becomes necessary during periodontal treatment, additional fees will be required.) Periodontics
Doctor
;Fee: Separate
Endodontics
Doctor
AND
SHEPPARD
fixed bridges/splints that extend from #3 to #7, #7 to #14, #22 to #27, and #27 to #30, #5 and #6 will initially be a metal resin temporary provisional prior to first implant surgery through second implant surgery. Then it will be removed and remade with attachment cylinders and resin veneers to function as gradual loading provisionals for the following 4 to 6 months. After a prefinalization review, #5 and 6 gradual-loading provisionals will be removed and reprocessed to replace resin veneers with porcelain for final placement. No provisionals are planned for #20 and 21 until the gradual loading provisional stage following second surgery. The procedures for carrying #20 and 21 through to finalization are the same as with #5 and 6. Dr. George Murrell; Fee: $ Note that this fee includes 5 above up to second surgery. Additional following procedures described in 5 will be charged out several months later as they are done. 6. Make impressions, develop the esthetic and functional tooth position for #s 5, 6, 20, 21, and fabricate upper and lower surgical stents for the surgeon. Dr. George Murrell; Fee: $ 7. First phase surgery. Surgically place Branemark type implant fixtures in approximate tooth positions: 5, 6,20, 21. Surgically perform hard and soft tissue plasty as necessary. Doctor ; Fee: Separate 8. Refit the provisional #5-#6 following first surgery, maintain postsurgical provisionalization and monitor tissue healing for 4 to 8 months. Dr. George Murrell; Fee: Included in #5 above. 9. Second phase surgery. Surgically attach transepithelial abutments to the osseointegrated implant fixtures. Surgically perform hard and soft tissue plasty as necessary. Doctor ; Fee: Separate 10. Fabricate osseointegrated implant metal superstructure frames with gold cylinder attachments to fit the new upper and lower abutments at #5 to #6 and #20 to #21. Maintain gradual loading and healing provisionalization for 4 to 6 months. Dr. George Murrell; Fee: $ 11. Conduct prefinalization review conferences with the patient and the surgeon to confirm the appropriate time to commence finalization and any desired modifications to be incorporated into the final prostheses. Remove upper and lower gradual loading prostheses, remove resin veneers, and replace with ceramic porcelain, place the final upper and lower implant prostheses, #5 to #6 and #20 to #21 into position. Dr. George Murrell; Fee: $ The total estimated fee for the recommended prosthodontic services described in this report is $ This applies to services rendered in this office only, it does not reflect any alternative treatment suggestions and does not include surgical or any other referred services. The estimated treatment time is 24 to 30 months depending on the duration of periodontics, endodontics, and the type of prosthodontic services being rendered. Except for major treatment changes or additional time or procedure requirements described earlier in this report, these fees will remain in effect if treatment commences by April, 1991 and is completed by October, 1993.
;Fee: Separate
Prosthodontics
Dr. George Murrell; Fee: Included above 5. Upon completion of active periodontal and endodontic treatment, perform all preparations, impressions, and try-ins necessary to fabricate and cement the following fixed prosthodontic restorations: Three (3) upper and two (2) lower porcelain-metal 972
Patient signature
Date
Witness Date DECEMBER
1992
VOLUME
68
NUMBER
6
INFORMEDCONSENTTREATMENTREPORT
5. Academy of Denture Prosthetics. Principles, concepts, pr0sthetics.J PROSTHETDENT 1989;61:88-109.
REFERENCES 1. Smith TJ. Informed consent doctrine. Y Law Eth Dent 1988;1:159-69. 2. Strauss MB. Familiar medical quotations. Boston: Little, Brown & Co, 1968;157-8. 3. Prosser W. Cases and materials in torts. St Paul, Minx West Publishing Co. 19'77;165-6. 4. Ebersold LA. Malpractice: risk management for dentists. Tulsa: PennWell Books, 1986;64.
Bound
volumes
and practices
in
Reprint requests to: GEORGE A.MuRRELL,DDS ~~O~SEPULVEDABLVD.,SUITE 200 MANHATTANBEACH,CA 90266
available
to subscribers
Bound volumes of THE JOURNAL OF PROSTHETIC DENTISTRY are available to subscribers (only) for the 1992 issues from the publisher at a cost of $55.00 ($68.00 international) for Vol. 67 (January-June) and Vol. 68 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 65 and 66 are also available. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA, phone (800) 325-4177, ext. 4351, or (314)453-4351. Subscriptions must be in force to qualify. in place of a regular JOURNAL subscription.
THEJOURNALOF
PROSTHETIC
DENTISTRY
Bound
volumes
are not available
973
