As a patient scheduled to have surgery involving my teeth and surrounding bone, I understand that the purpose of the procedure is to treat and possibly correct my diseased oral tissues. I realize that without treatment my present oral condition will probably worsen in time, and risks to my health may include, but are not limited to the following: swelling, pain, infection, cyst formation, periodontal (gum) disease, dental caries, malocclusion, pathologic fracture of the jaw, premature loss of teeth, and/or premature loss of bone. I understand the possible alternative forms of treatment, if any, but have freely chosen the planned procedure.

 

I am aware that in any surgical procedure there are inherent and potential risks. I understand that in this particular instance such operative risks include, but are not limited to:

 
  1. Postoperative swelling and discomfort, which may necessitate several days of home recuperation.
  2. Heavy bleeding that may be prolonged.
  3. Injury to adjacent teeth, fillings, or restorations.
  4. Postoperative infection requiring additional treatment.
  5. Stretching, cracking and/or bruising of the corners of my mouth.
  6. Restricted mouth opening for several days or weeks.
  7. Decision to leave a small piece of root in the jaw when its removal would require extensive surgery.
  8. Breakage or fracture of the jaw.
  9. Injury to the nerves in the area which can result in numbness, tingling , or pain of the lip, chin, ums, cheek, teeth and/or tongue of the  operated side. This may persist for weeks, months, or, in remote instances, permanently.
  10. Involvement of the sinus in the upper jaw, resulting in an opening into the mouth.
  11. General pain and discomfort related to the procedure.
 

I understand that the anesthetic methods offered to me were dependent upon my past medical history, and I have had an opportunity to discuss my medical history and present physical condition with Dr. Davis and/or an associate of Dr. Davis.

 

Having selected local anesthesia (and nitrous/oxide analgesia, and an oral analgesic) for pain control, I realize that nerve injury, bruising, or severe and harmful bodily reactions to the medication, though unlikely, are possible.

I realize that I should not operate any vehicle (i.e. drive an automobile) or hazardous devices, nor consume alcoholic beverages while under the effects of medications given to me during, or following, this procedure.

 

If any unforeseen condition arises during the procedure calling for additional treatment from that now contemplated, I request and authorize whatever measures deemed advisable by the doctor.

I realize that there is no guarantee that the proposed treatment will be curative and/or successful to my complete satisfaction. I am aware that individual patient differences result in the risk of failure, relapse, selective re-treatment, or worsening of the present condition, despite the care provided. I understand that failing to follow instructions concerning my care will increase the chances of a less than optimal result.

 
I certify that I read and write English and have read and fully understood this consent for surgery and local anesthesia (and analgesia). I have asked Dr. Davis and/or his associate(s) any questions I have concerning this procedure and the consent form and they have been answered to my satisfaction.
       
Date *
Patient's Name *
Signature of Patient, the Parent or Guardian
Witness *
Doctor *
       
Consent is hereby given for the following operation *
       
Date *
Patient's Name *
Signature of Patient, the Parent or Guardian
Witness *
Doctor *
       
 
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