Patient Waiver

1. I have been informed and provided ample time to fully understand the purpose and the nature of this restorative treatment. I understand the nature of my condition and of the propsed treatment.
2. My dentist has carefully examined my mouth and soft tissue. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an extraction of the recommended tooth or teeth.
3. I have further been informed of the possible complications and risks involved with surgery, drugs and/or anesthesia. Such complications may include pain, bruising, swelling, infection and discolouration. Numbness of the lips, cheeks or teeth may occur. The exact duration may not be determinable and may be irreversible. I am aware of possible sinus complications such as perforation or root tip in the sinus which could require further sinus treatments following this surgery. Also possible are thrombophlebitis (inflammation of the veins), referred pain to the ear or neck, stiffness of the neck and facial muscles, injury to the adjacent teeth, changes to my bite, bone fracture, delayed healing, allergic reaction to drugs or medications used, etc.
4. I understand that without treatment any or all of the following could occur: pain, bone loss, soft tissue inflammation, infection, decay, sensitivity, damage to other teeth and a more difficult procedure as the problem progresses and I grow older. Also, possible headaches and referred pain to the back of the neck and/or facial muscles.
5. My dentist has explained that there is no method to accurately predict the soft tissue and bone healing capability in each patient following the surgical procedure.
6. I understand that smoking, alcohol consumption, some medications, and certain medical conditions may affect healing.
7. I agree to follow my dentist's home care instructions. I agree to report to my dentist for regular examinations as instructed.
8. I agree to local anasthesia, depending on the choice of my dentist. Various options of sedation have been offered and discussed with me.
9. To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any prior allergies or unusual reactions to anaesthetics, pollen, dust, blood, or body diseases, gum or skin reaction, abnormal bleeding or any other conditions related to my health.
10. I consent to the intra and extra oral photographs and x-rays to be taken for clinical documentation purposes.
11. I agree to notify my dentist's office of any and all changes to my address and/or telephone number within a reasonable time frame (two to four weeks).
12. I consent to medical/dental services for myself, including upper extractions. I fully understand that an unforeseen procedure/surgery may become apparent, which warrants in the judgement of the dentist additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modifications in care, if it is felt it is for my best interest. If an unforeseen condition arises in the course of the treatment which calls for a procedure in addition to, or different from what initially intended, I further authorize and direct my dentist, to do whatever they deem necessary and advisable under the circumstance, including the decision not to proceed with the upper surgical extraction. 
13. I have had time to review this form and ask questions.
14. I have had all of my questions answered to my satisfaction.
15. I understand the treatment procedure and wish to proceed.