Form

Consent For Surgery

Dr. Issac

Patient Name

Date

1.) Pain, bleeding, and swelling which are inherent with most surgical procedures.

2.) Infection, which may require antibiotics, admission to the hospital, and additional/multiple surgeries.

3.) Injury to teeth, dental restorations, gum tissue, lips, tongue, floor of the mouth or underlying bone due to proximity to the surgical site.

4.) Difficulty opening the jaw after surgery due to pain or inflammation of the muscles.

5.) Uncontrolled bleeding that may require blood transfusion, hospitalization, or addition procedure.

6.) Nerve injury resulting in altered sensation of the face, lip, chin, and tongue, floor of the mouth. This can be temporary or permanent. The altered sensation can range from numbness, tingling, and in rare cases Pain.

7.) Sinus involvement: Generally, involves an upper back tooth or maxillofacial lesion such as infection, cyst, or tumor. This may result in a persistent opening from the sinus to the oral cavity causing fluids to enter the nose or mouth. Additional surgery may be needed to correct this complication.

8.) Tooth fragment may be left in place, if its removal would cause injury to the surrounding structures such as nerves, or result in it getting dislodged into the sinus, floor of the mouth, or other areas in the face or neck. Additional surgery may be needed to remove the fragment.

9.) TMJ (temporomandibular joint) dysfunction: treatment in my mouth can have an adverse outcome on the TMJ resulting in persistent pain and/or limited mouth opening.

10.) Reaction to local anesthesia such as a fast heartbeat, altered mental status, seizures, sweating, shortness of breath, chest pain, rash, or hives. In rare cases this may be life threatening.

11.) Sharp bony areas or bone spur may occur, which may require additional surgery to recontour the bone or remove the bone spur.

12.) Drug reaction resulting in hives, rash, nausea, vomiting, and/or headaches, admission to the hospital or emergency department.

13.) Fracture of the jaw due to the impaction of the tooth. I understand if my jaw is fractured, I will need to be on a liquid/soft non-chew diet. In addition, I may need additional surgery such as plates and screws over the fracture site, and/or placement of arch bars/wires which will limit my mouth opening for several weeks.

14.) Failure of the dental implant to integrate resulting in the need to remove the implant, additional surgeries such bone grafting or sinus left, and/or placement of a new dental implant.

15.) Swallowing aspiration of the tooth, bone, foreign body, or bodily fluids. I understand if this occurs I may need additional imaging, admission to the hospital or emergency department, and/or additional surgery.

16.) Fainting, loss of consciousness, and altered mental status due/ or not to existing disease.

17.) I verify that I am not pregnant. If I am pregnant, I understand that surgery or delay of surgery or medications prescribed may result in premature labor, birth defects, injury to the mother and fetus. And I understand that the surgeon/ dentist might be limited in terms of prescribing medications in case of pregnancy.

18.) I understand that taking antibiotics may interfere with my birth control medication. Other methods of contraception should be used until your next menstrual cycle.

19.) I understand I may need additional surgery if the body fails to heal properly or if the results of the biopsy indicate additional treatment is needed.

20.) In the event of an emergency, I give permission to the surgeon/ dentist and his office staff to deliver treatment that may save my life.

21.) I am not currently on or have been on any medications known as bisphosphonates such as Fosamax (Alendronate), Boniva (Ibandronate), Actonel (Risedronate), Zometa (Zoledronic acid), Prolia/ AGEVA (Denosumab)

22.) I have not had head and neck radiation for the treatment of cancer.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date