If you have any questions, please ask your doctor BEFORE signing.

What you are being asked to sign is confirmation that you have been given information on the nature of your proposed treatment and the known risks associated with it.

2. GENERAL RISKS OF BONE GRAFTING

A.  Bleeding, swelling or infection at the donor site requiring further treatment.

B.  Allergic or other adverse reaction to drugs used during or after the procedure.

C.  The need for additional or more extensive procedures in order to obtain          sufficient bone for grafting.

3. RISKS AND COMPLICATIONS OF GRAFTING FROM WITHIN THE MOUTH AREA

A.  Damage to adjacent teeth, which may require future root canal procedures, or may cause loss of those teeth.

B.  Removal of adult teeth in order to obtain sufficient bone material.

C.  Numbness or pain in the area of the donor or recipient site, or more extensive areas, which may be temporary or permanent.

D.  Penetration of the sinus or nasal cavity in the upper jaw which could result in infection or other complication requiring additional drug or surgical treatment.

4. RISKS OF FREEZE-DRIED, DEMINERALIZED OR OTHER BANKED BONE

On occasion, additional donated bone is used to supplement the patient's bone, or to spare an extensive donor site surgical procedure. Use of such bone may involve separate risks including, but not limited to:

A.  Rejection of the donated graft material together with the entire graft.

B.  The remote chance of disease transmission from processed bone.

6. ANESTHETIC RISKS include:

Discomfort, swelling, bruising, infection, prolonged numbness and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) which may cause prolonged discomfort and/or disability, and may require special care. Nausea and vomiting, although rare, may be unfortunate side effects of IV anesthesia. Intravenous anesthesia is a serious medical procedure and, although considered safe, carries with it the risk of heart irregularities, heart attack, stroke, brain damage or death.

7. YOUR OBLIGATIONS IF IV ANESTHESIA IS USED

A.  Because anesthetic medications cause prolonged drowsiness, you MUST be accompanied by a responsible adult to drive you home and stay with you until you are recovered sufficiently to care for yourself. This may be up to 24 hours.

B.  During recovery time (24 hours) you should not drive, operate complicated machinery or devices, or make important decisions such as signing documents, etc.

C.  You must have a completely empty stomach. IT IS VITAL THAT YOU HAVE NOTHING TO EAT OR DRINK FOR SIX (6) HOURS PRIOR TO YOUR ANESTHETIC. TO DO OTHERWISE MAY BE LIFE-THREATENING!

D.  However, it is important that you take any regular medications (high blood pressure, antibiotics, etc.) or any medications provided by this office, using only a small sip of water.

8.  It has been explained to me and I understand that a perfect result is not, and cannot be guaranteed or warranted.

 

CONSENT:

I certify that I speak, read and write English and have read and fully understand this consent for surgery, and that all blanks were filled in prior to my initialing and signing this form and that all my questions were answered to my satisfaction.