Child Frenectomy Informed Consent Form Diagnosis: After a thorough oral examination, my dentist has advised me that the revision of a frenum in my child’s mouth may help to restore anatomy function and/or prevent commonly associated future problems.
Recommended Treatment: In order to treat this condition, my child’s dentist has recommended that a frenectomy be performed at the selected site or sites.
Principle Complications: I understand that a smooth recovery is expected; however, there are always associated risks that cannot be eliminated and may occur in a minority of cases. These complications include but are not limited to post-surgical bleeding, infection, swelling, tenderness, discomfort, and damage to adjacent structures such as salivary glands, nerves, muscles, or skin. A more common complication is re-attachment of the frenum. Genetics also plays a strong role in healing, such as the formation of scar, keloid, or overt fibrous tissue formation.
Follow Up: I am advised to return for a 1-week check.
Alternatives to Suggested Treatment: I understand that alternatives to a frenectomy include no frenectomy, with the expectation that the frenum does not normally improve but may aggravate the surrounding tissues, including the gums and teeth.
No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. I do expect, however, that the doctor performs the surgery to the best of his ability.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT AND ALL MY QUESTIONS WERE ANSWERED.