Consent For Oral Surgery printable pdf download

INFORMAT IONAL USE ONLY

CONSENT FOR ORAL SURGERY

RECOMMENDED TREATMENT

I give permission to Dr. ____________________________ to perform the following

treatment as well as any additional procedures considered necessary on the basis of

findings during the actual surgery. This permission is for myself (or my ward or minor

child) named below. I fully understand this consent for surgery and t he reasons why the

recommended treatment is necessary. I have been given the oppo rtunity to ask questions

regarding the recommended treatment and have been given satisfactory answers. I

understand that no guarantee regarding the treatment has been made or implied.

TREATMENT: __________________________________________________________

_______________________________________________________________________

TREATMENT ALTERNATIVES

I elected the treatment listed above even though the following alternatives have been

explained to me as being both practical and possible.

TREATMENT ALTERNATIVES: ___________________________________________

________________________________________________________________________

ANESTHESIA/MEDICATIONS

I also authorize the recommended treatment to be performed with the following

anesthetics and/or medications:

_____ Local anesthesia only

_____ Local anesthesia with nitrous oxide and oxygen

RISKS AND CONSEQUENCES

I understand that there are risks associated with the administration of medications and

performance of the recommended surgery such as the items check below:

_____ Drug reactions and side effects

_____ Post-operative bleeding and pain

_____ Necessary removal of bone during tooth extraction

_____ Post-operative infection or bone inflammation

_____ Possible damage to the sinus when upper back teeth are removed which may

require surgical repair at a future date

_____ Possible nerve damage when lower wisdom teeth are removed which can result

in either temporary or permanent tingling or numbness in the lower lip

_____ Fracture of the mandible

_____ Jaw joint (TMJ) pain, malfunction and/or difficulty in opening mouth due to

muscle spasms, following removal of lower teeth

_____________

______________________________________________________

Date

Patient or Patient’s Guardian

_____________

______________________________________________________

Date

Witness

Consent For Oral Surgery