GENERAL ORAL SURGERY:
1. Injury to adjacent teeth or fillings.
2. Post-operative infection requiring additional treatment.
3. A root tip may be left in the jaw when its removal would require extensive surgery.
4. Breakage of the jaw.
5. Several days at home may be required due to swelling and discomfort.
6. Stretching of the corners of the mouth with resultant cracking and bruising.
7. Injuring the nerve under the teeth causing a numb lip and/or tongue on the surgery side.
8. Opening the sinuses (a normal cavity above the upper teeth only) requiring more surgery.
WISDOM TEETH (IN ADDITION TO ABOVE:
1. The nerve to your lip runs through the jaw very close to the wisdom teeth. In some cases it actually runs through the tooth roots and cannot be seen on the x—ray. There is a possibility of damage to this nerve.
2. The nerve to the tongue runs in the gum very close to the wisdom teeth. The path of this nerve is different in each person and cannot be known by the doctor. This nerve can be stretched or damaged in the normal course of removing a tooth or when the needle used to place the numbing medicine is inserted in the gums.
If either of these nerves is damaged, it could result in numbness in the lip and/or tongue on the surgery side. Should either of these happen, we will follow you closely to evaluate the regeneration of the nerve. This numbness usually clears up aver several months’ time; however, in rare cases, it can be permanent. If there is a continuing problem, it is possible that we would refer you to a specialist to reconstruct the nerve with microscopic surgery.
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GENERAL ANESTHESIA (SEDATION):
1. People react differently to medicines. Some become excited, others cry; most have no
reaction at all. The time it takes for you to recover is an individual response.
2. Irritation of the veins, allergies or rashes are possible reactions.
3. As with any anesthetic, there are unforeseen problems which do occur very rarely.
This office has the appropriate equipment and the staff has been trained to handle any emergency which could develop. Please feel free to discuss your questions with us prior to signing this consent. By signing you give up no rights and do not relieve the surgeon of any responsibilities. Please sign and date below if you understand all of the above and do not have any questions.
"I GIVE MY PERMISSION FOR THE ANESTHETIC AND ORAL SURGICAL PROCEDURES AGREED UPON BY MYSELF AND DR. SMITH/GRAY/MORRIS. THE PROPOSED SURGERY AND RISKS HAVE BEEN EXPLAINED TO MY SATISFACTION. I ALSO VERIFY THAT THE INFORMATION GIVEN ON MY HISTORY SHEET IS CORRECT TO MY KNOWLEDGE."
| ____________________________________ SIGNED (Patient, Parent if Minor) |
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VB: ______) Date |
"I HEREBY AUTHORIZE THE DOCTOR TO RELEASE INFORMATION RELATED TO THIS CLAIM. I FURTHER AUTHORIZE PAYMENT DIRECTLY TO THE DOCTOR OF BENEFITS DUE ME FOR HIS SERVICES. I UNDERSTAND THAT I AM RESPONSIBLE FOR CHARGES NOT COVERED BY THIS AUTHORIZATION."
| ____________________________________ SIGNED (Patient, Parent if Minor) |
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(VB: ______) Date |