I understand that the purpose of the procedure/ surgery is to treat and possibly correct my diseased oral/ maxillofacial tissues. I have been advised that if this condition persists without treatment or surgery my present oral surgery will worsen in time and the risk to my health may include, but are not limited to the following swelling, pain, infection, cyst formation, gum diseases, dental caries, malocclusion , premature loss of teeth and or premature loss of bone. I have been informed of possible alternative methods of treatment, if any.

The Doctor has explained to me that there are certain inherent and potential risks in any treatment or procedure-which include, but are not limited to:

No guarantee or assurance has been given to me that the proposed treatment will be curative and/ or successful to my complete satisfaction. Due to the individual patient differences ? exists a risk of failure. Relapse, selective treatment, or worsening of my present condition despite the care provided.

However, it is the doctor’s opinion that therapy would be helpful, and that a worsening of my condition would occur sooner without the recommended treatment.

I have had an opportunity to discuss and have made a full disclosure of my past medical and health his tory including any serious problems and/ or injuries. This includes any past or present substance abuse.

Because successful treatment often depends upon compliance with a Doctor’s instructions, I agree to cooperate completely with the recommendations of the doctor and/or his/her assistant while I am under his/her care, realizing that any lack of same could result in a less than optimum result.

I acknowledge that Dr. Nazari and/or Antoine Dental Center exercises no right of control over the independent contracted provider’s dental practice methods, procedures, tools, instruments, or execution of treatment. I agree that the independent contracted provider is solely responsible for his/her own patient diagnosis and treatment to the extent that I acknowledge that Dr. Nazari and/or Antoine Dental Center is not liable for any of the independent contracted provider’s dental practices, procedures, including but not limited to the diagnoses and dental treatment performed on me. I further agree that I will hold Dr. Nazari and/or Antoine Dental Center harmless from any and all suite, claim, and causes of actions of any matter that could be brought against the independent Contracted Provider.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION AND RHE EXPLANATION REFERRED TO OR MADE. AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS.

I ALSO STATE THAT I READ AND WRITE ENGLISH.