Oral Surgery Consent Form printable pdf download

Oral Surgery Consent Form

B225‐3122 Mount Lehman Rd

Abbotsford, B.C. V2T‐0C5 (604)381‐3399

Oral Surgery Consent Form

Patient:____________________________ Date:__________________________

I, _____________________________________ consent to the preforming of the

prescribed surgery procedure(s) including the use of local anesthetic (dental

freezing) as indicated. I have been informed of the potential risks of such

procedure(s) including but not limited to:

1. Temporary or permanent numbness of the lip and/or tongue

2. Dry socket

3. Bleeding

4. Bruising

5. Swelling

6. Oral antral communication (opening between tooth socket and sinus)

7. Infection

The prescribed treatment of ___________________________________________

has been explained to me along with the alternative(s), including not having any

treatment done. I understand the benefits and importance of such treatment and

will assume the responsibility for the fees associated with these procedures.

Patient/Guardian

Witness

Oral Surgery Consent Form