• Dental And Oral Surgery Consent Form

    Fairway Dental Clinic

    385 Fairway Road South, Unit #203
    Kitchener, Ontario, Canada N2C 2N9
    Phone: 519-893-9494

    I have been advised that without treatment, my current oral condition can result in swelling, pain, infection, cyst formation, periodontal (gum) disease, dental decay, pathologic fracture of the jaw, premature loss of teeth and/or premature loss of bone.
  • Oral surgery can involve the following complications:
    • The most common complications from oral surgery are pain, infection, swelling, bleeding, and bruising
    • Removal of tooth may necessitate sectioning of tooth and/or removal of bone and tissue surrounding extraction site resulting in increased local discomfort
    • Post operative infection requiring further treatment
    • Damage to adjacent/opposing teeth or restorations
    • Temporary or permanent nerve damage from the extraction of teeth in the lower jaw resulting in altered and/or loss of sensation in the lip, tongue, chin, teeth and/or soft tissue
    • Opening into the sinus during extraction of upper teeth requiring further treatment
    • Small fragments of tooth or bone may not be removed due to an increased risk of surgical complications and may require additional surgery
    • Weakness and potential fracture of the jaw due to removal of the wisdom teeth
    • Referred pain to the pain and neck, nausea and allergic reactions
    • Temporary or permanent Temporomandibular joint soreness, limited opening, pain on opening or locking
    • Delayed healing due to preexisting medical conditions and/or extent of the surgery
    • Infection of the extraction socket (dry socket)
    • Biting of the numb lip which may cause damage following removal of the teeth. You need to be watched closely by the parent/caretaker until the numbness wears off.
    If complications arise I may miss school or work schedules or I may incur additional, unexpected expenses, including, but not limited to, expenses for other dentists, doctors, or medical facilities.

    Medications, anesthetics and sedation may cause drowsiness and lack of awareness and coordination. Thus I have been advised not to work or to operate any vehicle while taking medications and until fully recovered from the post operative effects.

    If any unforeseen condition should arise in the course of the operation, calling for the doctor’s judgment for procedures in addition to or different from those presented, I request and authorize the doctor to proceed with any and all necessary procedures even if different than discussed preoperatively.

    I have had the opportunity to discuss with the doctor any and all details of my medical and health history including any serious conditions and/or medications currently taking.

    I have been given an opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I believe that I have sufficient information to give this consent.

    I understand that photographs or video footage may be taken during my operation. These may then be used for teaching health professionals. You will not be identified in any photo or video.

    I understand that no warranty or guarantee has been made to me as to result or cure. I HAVE READ AND UNDERSTOOD THAT THERE ARE INHERENT RISKS ASSOCIATED WITH THE REMOVAL OF TEETH. I ALSO UNDERSTAND THAT SHOULD COMPLICATIONS ARISE, A REFERRAL TO AN ORAL SURGEON MAY BE NECESSARY AND IN MY BEST INTEREST.   I was able to ask questions and raise concerns with the dentist about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.
  • (Write Your Name)
  • (Write Your Name)
  • .
    DD slash MM slash YYYY