I understand that, if I desire, sedative drugs may be used to reduce anxiety and discomfort by making me relaxed and sleepy. These drugs may also reduce my ability to remember events occurring on the day of the operation. I understand and agree that I will not drive myself home following surgery, but will be driven home by a responsible adult who will stay with me until I am fully recovered from the effects of the anesthetic medications or prescription pain-relievers that have been prescribed for me. I agree not to operate a motor vehicle or hazardous machinery for at least 24 hours following surgery.
In the event that the removal of any teeth, or parts of teeth, is deemed advisable by the Doctor due to conditions visualized and determined at the time of surgery, I consent to such removal.
If unforeseen conditions should arise during the course of the operation, calling for the Doctor's judgment or for procedures in addition to or different from those now contemplated, I further request and authorize the Doctor to do whatever he may deem advisable.
Further, I have been informed that other possible alternatives and/or supplemental methods of treatment exist.
Post-operative risks of the proposed surgery include, but are not limited to: swelling; infection; discomfort; Herpes Simplex I (cold sores/fever blisters); restricted mouth opening for several days, weeks or longer; paresthesia (numbness) of the jaw or gum nerves which may persist for several weeks, months, or in remote instances, permanently; gum recession (shrinking--teeth appear to be longer than before; unesthetic exposure of crown (cap) margins; temporary, or in rare instances, permanent interference with phonetics (speech sounds); clicking or pain of the temporomandibular joints (jaw joints); tooth sensitivity to hot or cold for days, weeks, or on occasion, several months, in rare instances endodontic (root canal) therapy may be needed; transient, or in some instances permanent, tooth mobility (looseness) in selected areas; food lodging between teeth after meals, requiring cleaning devices such as dental floss for removal.
I understand that if I smoke, I am more likely to experience complications.
I further understand that if no treatment is rendered, my present condition may worsen in time.
I understand that the practice of dentistry is not an exact science and that reputable practitioners cannot guarantee results. No guarantee, warranty, or assurance has been given to me that proposed therapy will be successful to my complete satisfaction. Due to individual patient differences there exists a risk of failure, relapse, selective re-treatment, or worsening of my present condition to include the possible extraction of certain involved teeth despite the best of care. However, it is my Doctor's opinion that therapy will be helpful, and that any further loss of supporting tissues or bone would occur sooner with out the recommended surgery.
To my knowledge I have reported to the Doctor any prior drug reaction, allergies, diseases, symptoms, habits, and medications which may be in any way related to this procedure. I understand that my diligence in providing the personal daily care recommended by the Doctor and taking all medications prescribed by the Doctor is important to the ultimate success of the procedure.
The Doctor has informed me of the importance of follow-up care. This follow-up care includes recommended cleaning and re-exam intervals by the Doctor in addition to recommended re-examination by a general dentist. I understand that the Doctor does not perform restorative procedures (fillings, crowns and bridges, etc.), and that I must make an appointment with the general dentist of my choice for those procedures where indicated.
My Doctor has explained alternative treatments. I understand that it is important for me to continue to see my general dentist. I recognize the need to come to my post-operative appointments so the Doctor can monitor my healing and report on the outcome of the surgery upon completion of healing. Smoking or alcohol intake may adversely affect healing and may limit the successful outcome of surgery.