This form and your discussion with your dentist are intended to help you make an informed decision about your surgery.

1. I give consent for my dentist and/or any dentist and dental assistants who are working with him or her to perform the following treatment/procedure/surgery. You have been informed of your diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the procedure, and any associated costs.

2. I understand the nature of the procedure and that the purpose of the procedure is to treat my diseased oral/maxillofacial tissues and/or extract teeth. The doctor has advised me that if this condition persists without treatment or surgery, my present oral condition may or may not worsen in time, and the risks to my health may include, but are not limited to, the following: swelling, pain, infection, cyst/tumour formation, periodontal (gum) disease, dental caries, malocclusion, pathologic fracture of jaw, premature loss of teeth, and/or premature loss of bone. I acknowledge that the procedure(s), its implications and possible complications have been explained to me, and I have been informed of possible alternative methods of treatment, if any.

3. I have been advised of possible complications of this procedure that are to be reasonably anticipated. They include but are not limited to:

• Injury to a nerve, resulting in numbness or tingling of the chin, lip, cheek, gums, and/or tongue to the operated side. This may persist for several weeks, months, or, in remote instances, permanently.
• Postoperative infection requiring additional treatment.
• Postoperative discomfort, swelling, and bleeding that may necessitate several days of recuperation.
• Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
• Restricted mouth opening for several days or weeks (with possible dislocation of the temporomandibular jaw joint.
• Injury to adjacent teeth and fillings.
• Bruising of skin and gums
• Decision to leave a small piece of root in the jaw when its removal requires extensive surgery.
• Stretching of the corners of the mouth with resultant cracking and bruising.

4. Depending on their strength, certain medications, drugs, anaesthetics and prescriptions may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs. Thus, I have been advised not to operate any vehicle, automobile or hazardous devices, or work, while taking such medications and/or drugs; or until fully recovered from the effects of same. If sedation is given I understand and agree not to operate any vehicle or hazardous device for at least twenty-four (24) hours after my release from treatment or until further

recovered from the affects of the anaesthetic medication and drugs that may have been given to me in the office. I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me home after my discharge.

5. I acknowledge receiving a copy of the post-operative instructions, which have been explained to me. I understand all the advice given to me by my dentist. After my procedure is complete, I will notify my dentist if I experience any acute pain, heavy bleeding from the surgical site, respiratory problems, or any other post-operative problems.

6. I understand that no guarantee can be given of the results of surgery on the human body, but that the doctor and office staff will do their best to achieve excellent results.

7. I agree to cooperate with the recommendations of the dentist while I am under his or her care, realizing that any lack of same could result in a less than optimum result, and I agree to attend post-operative assessment appointments when necessary.

8. All my questions concerning this procedure have been answered to my satisfaction.

You should consider all of the above, including the option of declining treatment. Your dentist will be happy to answer any further questions you may have and provide additional information before you proceed with the procedure.