Consent For Oral Surgery And Anesthesia
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3CONSENT FOR ORAL SURGERY AND ANESTHESIA
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______________________________________________________________________
Patient’s Name
Date
Please initial each paragraph after reading. If you have any questions, please ask
your doctor BEFORE initialing.
You have the right to be informed about your diagnosis and planned surgery so that you
can decide whether to have a procedure or not after knowing the risks and benefits.
Your diagnosis is: _______________________________________________________
Your Planned Treatment is:
Alternative treatment: methods include:
Whether a procedure is easy or difficult, it is still a surgical procedure. All surgeries
have some risks. They include the following and others:
1.
Swelling, bruising and pain.
_____2.
Possible infection that might need more treatment.
_____3.
Changes in the bite or difficulty in opening the mouth because of stress on the jaw
joint (TMJ) may happen.
_____4.
Possible damage to other teeth close to the ones being taken out, (more often those
with large fillings or caps), or other tissues of the face or mouth might be harmed.
_____5.
It is very rare that the bones of the jaw will break, but it is possible in cases where
the teeth are buried very deep in their sockets.
_____6.
Healing could take longer
_____7.
The place where the tooth was taken out could be very painful (dry socket).
_____8.
I might have a reaction to a medicine.
9.
Sharp ridges or bone splinters may form later at or near where the tooth was taken
out. These may need another surgery to smooth or remove.
____10.
The hole where the tooth had been might need more care, or small pieces of the
tooth root might be left there to prevent damage to very important things like nerves
or a sinus (a hollow place above your upper back teeth).
____11.
Upper back teeth are often close to the sinus and sometimes the tooth or a piece of
root can get into the sinus and need more treatment. An opening may occur from
the sinus into the mouth that may need more treatment.
____12.
The roots of the lower teeth might be very close to the sensory nerve and after the
surgery; there might be pain or a numb feeling in the chin, lip, cheek, gums, teeth or
tongue. It is possible that you might lose your sense of taste. This might last for
weeks or months and can be permanent.
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