Oral Surgery Informed Consent I UNDERSTAND THAT ORAL SURGERY INCLUDES INHERENT RISKS SUCH AS, BUT NOT LIMITED TO THE FOLLOWING: Injury to the nerves: This would include injuries causing numbness of the lips, the tongue, any tissues of the mouth and/or checks or face. This numbness which could occur may be a temporary nature, lasting a few days, a few weeks, a few months, or could possibly be permanent and could be the result of surgical procedures or anesthetic administration. Bleeding, bruising, swelling: Bleeding may last several hours. If profuse, you must contact us as soon possible. Some swelling is normal but, if severe, you should notify us. Bruises or hematomas may persit for some time. Dry socket: This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry sockets can be extremely painful if not treated Sinus Involvement: In some cases, the root tips of upper teeth lie in close proximity to the sinuses. Occssionally during the extraction or surgical procedures, the sinus membrane may be perforated. Should this occur, it may be necessary to hav the sinus surgically closed. Root tips may need to be retrieved from the sinus. Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile or injected oral environment, for infections to occur post-operatively. At times these may be of a serious nature. Should severe swelling occur, particularly accompanied with fever or malaise, attention should be received as soon as possible. Fractured jaw, roots, bone fragements, or instruments: Although extreme care will be used, the jaw, teeth roots, bone spicules, or instrument used in the extraction procedure may fracture or be fractured, requiring retrieval, and possible referral to a specialist. A decision may be made to leave a small piece of root, bone fragment, or instrument in the jaw when removal may require additional extensive surgery, which could cause more harm and add to the risk of complications. Injury to adjacent teeth or fillings: This could occur at times no matter how carefully oral surgery procedures are performed. Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, the tissues of the heart, as a result of reasons known or unknown, may be susceptible to bacterial injection transmitted through blood vessels, and bacterial endocarditis (an infection of the heart) could occur. It is my responsibility to inform the dentist of any heart problems known or suspected. Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. All prescription drugs must be taken according to instructions. Women using oral contraceptives must be aware that antibiotics can render these contraceptives ineffective. Other methods of contraception must be utilized during the treatment period. It is my responsibility to seek attention should any undue circumstances occur post-operatively and I shall diligently follow any pre-operative and post-operative instructions given to me. INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and/or extraction of teeth and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. J. Scott Travelstead and his associates to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications.Are you taking or have you ever taken the following medications? If yes, please list dates below.Aredia? Yes No If yes, please list dates: Zometa? Yes No If yes, please list dates: Pamisol? Yes No If yes, please list dates: Fosamax? Yes No If yes, please list dates: Actonel? Yes No If yes, please list dates: Boniva? Yes No If yes, please list dates: Reclast? Yes No If yes, please list dates: Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Name(Required) Patient Signature(Required)Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name Parent/Guardian Signature Δ
