APPROVAL OF WAX TRIAL DENTURE PROSTHESIS AND CONSENT TO PROCEED WITH DENTURE PROCESSING - I have been given the

opportunity to view and wear my wax trial denture prosthesis. - I have been given the opportunity to inform the dentist about the changes I desire and these changes were made to my satisfaction. I approve the color, shape and positions of the denture teeth. I also approve the way it looks and feels in my mouth. - I approve the lip support and facial esthetics with the wax trial denture in the mouth. - I understand that speech patterns as a result of the denture teeth positions can take some time to get adapted to. - I understand that once the wax trial dentures are processed in the laboratory, the positions of the denture teeth and overall appearance cannot be changed without additional and possibly significant time being taken and clinical and laboratory fees assessed. - I understand that the final prosthesis will include artificial gums made of acrylic resin (plastic) to replace the lost tissues and for dental and facial esthetics. The color of the denture gums will not match the color of my underlying soft tissues.

By signing this consent form, I am hereby approving the wax trial denture prosthesis and freely giving my consent to: Dr. ENTER DOCTOR NAME HERE and/or his/her associates to proceed with working with the dental laboratory for denture processing. Patient's name (please print) Signature of patient, legal guardian or other authorized representative Witness to signature