Consent for Oral Surgery

Dentist and orthodontist family
Consent Oral Surgery
____________________________________________________     I hereby authorize
Patient Name
Dr. Bryan Bauer to perform the following procedure __________________________
The doctor has explained to me the proposed treatment and the anticipated results.  I understand there are possibly alternative forms of treatment.  The doctor has explained to me that there are certain potential risks involved with this procedure and include:
  1. Postoperative pain, swelling and bleeding.
  2. Dry socket, pain in tooth socket typically occurring 2-3 days after extraction.
  3. Stretching of the mouth corners resulting in cracking and/or bruising.
  4. Postoperative infection that may require more treatment.
  5. Restricted mouth opening for several days or longer.
  6. Injury to surrounding teeth and dental work.
  7. Injury to a nerve resulting in numbness or tingling of the chin, lip, gums, cheek, teeth and/or tongue on the operated side.  This may persist from a few days to several months and in very rare instances permanently.
  8. Opening of the maxillary sinus (a normal body cavity or space above upper teeth) requiring an additional surgery.
  9. Decision to leave a small piece of the root in the jaw when removal would require extensive surgery.
  10. Broken jaw and/or temporomandibular (jaw) joint trauma or damage.
_________________________________
Unforeseen conditions may arise during the procedure that require a different approach to the extraction and/or additional procedures.  I herby authorize the doctor to perform these procedures as he, in his professional judgment, deems necessary.  I have had an opportunity to discuss with Dr. Dettmer/Bauer my concerns with this treatment.  I have provided the office with my current medical history and all health history and medications I am taking.  I agree to follow the post-operative instructions as set forth by the doctor.
Patient, parent, or guardian
________________________                                                           __________________

Doctor