Oral Surgery Consent Form

ORAL SURGERY CONSENT FORM
Date*

MonthDayYear
Name*

First NameLast Name
Email*
example@example.com
This is my consent for Dr. Korwin and associates to perform the following surgical procedure:
Procedures
or future surgical procedures. I have been provided the opportunity to ask questions about the procedure and the alternatives. I understand that surgery is required for this procedure with the potential for discomfort and infection that may last for one week or longer. Further, because of the nature of this surgery, treatment and post-treatment factors include but are not limited to, the following risks:
READ AND DISCUSS EACH ITEM BELOW. INITIAL EACH LINE ONLY AFTER YOU UNDERSTAND EACH MEANING.
1. Post-operative discomfort and swelling that may necessitate some home recuperation.
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2. Post-operative sensitivity or spacing between teeth that may require additional treatment.
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3. Bleeding that may be prolonged.
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4. Injury to adjacent teeth or fillings.
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5. Pre or Postoperative infection requiring additional treatment.
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6. Stretching of the corners of the mouth may result in cracking and bruising.
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7. Restricted mouth opening for several days or weeks.
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8. The leaving of a small piece of root in the jaw when its removal would require more extensive surgery.
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9. Fracture of underlying bone if it is weak.
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10. Injury to the nerve underlying the teeth resulting in numbness or tingling of the lips, chin, gums, cheek, teeth, and or tongue which may be temporary or permanent.
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11. Gum Recession may occur requiring additional treatment.
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12. Despite precautions, items may be swallowed when patient is numb.
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13. I consent to the accession of tissue and the submission of any pathological specimen found during my surgery and the additional doctor of lab fees involved in any necessary biopsy.
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I understand the items above, which I have initialed. Despite my being informed of these risks, and being offered additional time for consideration, I request that this procedure be performed now.
I have had an opportunity to discuss my past medical and health history including any serious problems and/or injuries.
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I understand that I have the option of a referral to a specialist for this treatment.
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I CERTIFY THAT I HAVE HAD AMPLE OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION, AND THE EXPLANATION OF EACH ITEM.
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Date

MonthDayYear
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Date

MonthDayYear
CARE FOLLOWING SURGICAL DENTAL PROCEDURES
Proper care of the mouth following extractions can reduce most complications and speed healing.

1.         Preventing Bleeding: maintain gentle pressure by biting on a gauze sponge that has been placed over the surgical area (or by biting on a tea bag that has been gently moistened and wrapped in piece of gauze). Keep steady, firm pressure for 60 minutes. Repeat with a new gauze as often as needed. There may be normal blood stains in the saliva for hours or days after treatment. If a packing was placed, (or a denture is used) your packing will provide pressure and will take the place of gauze.

2.         Do not rinse, spit, or use a mouth wash for at least 24 hours, rinse with warm, salt water. 1/2 teaspoon of table salt in 8 oz. water every 1-2 hours is recommended. Use Natural Dentist mouth rinse after 2 days, the use of stronger over the counter mouth washes may delay healing and is not recommended.

3.         Discomfort following dental surgery is normal. If medication had been prescribed, take as instructed. It may take 20 minutes or so before medication is effective.

4.         The toothbrush may be carefully used in the area of the mouth not involved with the surgical procedures. A clean mouth heals faster. After 24 hours, brush carefully around the treated area.

5.         Eating: adequate intake of food and fluid following surgery or extractions is especially important. You may eat when bleeding has stopped. Stay on a soft-cool diet, you may use liquid diet supplements. Daily multi-vitamins are also helpful including vitamin C and CoQ-10. Avoid highly seasoned and spicy foods.

6.         Avoid all strenuous and excessive activity. Do not pick at the surgical area, don't consume liquids through a straw, avoid alcoholic beverages and refrain from smoking until healing is well established. Eat on the other side.

7.         If non resorbable sutures were used, do not fail to return for their removal on the appointment date given.

8.         Control of swelling: gently apply ice packs to the area for periods of 10 minutes on, 10 minutes off Ice should be used for the first 24 hours only. Swelling is normal after surgery and ice will help to minimize it. After the first day discontinue ice and begin to use mild heat.

9.         Allergic reactions: for generalized rash, itching, etc., discontinue all medications immediately and call your physician and our office. You may have a normal brief feeling of weakness or chills during the next two days. This may not be an allergic reaction.

10.       Please call if any questions arise. If your call is at a late hour, our answering service will put you in touch with the doctor.
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ORAL SURGERY CONSENT FORM

CARE FOLLOWING SURGICAL DENTAL PROCEDURES