DENTAL TREATMENT CONSENT
I Hereby authorize Dr . ____________________________ and such assistants as may be selected by any of them , to treat the condition ( s ) described below : ______________________________________________________________________
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The procedure ( s ) necessary to treat the condition ( s ) have been explained to me and I understand the nature of the procedure to be : _________________________________________________________________________________________
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I have been informed of possible alternative methods of treatment ( if any ).
I have further understood that this is an elective procedure and other forms of treatment or no treatment at all are all choices that I have and that this treatment ( in my doctor ’ s opinion ) will provide the optimum relationship between teeth , jaws , muscles , and the temporomandibular ( jaw ) joint that is possible at this time .
The doctor has explained to me that there are certain inherent and potential risks in any treatment plan or procedure , and some of the operative and anesthesia risks include , but are not limited to the following :
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Post-operative / treatment discomfort and swelling , that may necessitate several days of home recuperation .
Heavy bleeding that may be prolonged .
Injury to the adjacent teeth and fillings , causing loss of a tooth or teeth or need for restorations or root canal therapy .
Development of a dry socket — localized alveolitis — requiring extended treatment .
Post-operative infection requiring additional treatment .
Delayed healing requiring additional treatment .
Stretching of the corners of the mouth with resultant cracking and bruising .
Restricted mouth opening for several days or weeks .
Decision to leave a small piece of root in the jaw when its removal would require extensive surgery or nerve damage .
Breakage of the jaw .
Swallowing of tooth ; swallowing of tooth with tooth being lodged in the lung , requiring a chest x-ray and subsequent surgical removal .
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Injury to the nerve underlying the teeth resulting in numbness , tingling , painful or altered sensation in the lip , chin , cheek , gum , teeth , and / or tongue on the operated side ; this may persist for several weeks , months or in remote instances , permanently .
Opening of the sinus ( a normal cavity situated above the upper teeth ) requiring additional surgery . A sinus infection may develop , or loss of a piece of tooth or whole tooth in the sinus requiring recovery .
Stiff neck or facial muscles .
Changes in the bite or pain of the Temporomandibular joint ( ear / jaw joint ).
If intravenous medication is used , soreness at the injection site or along the vein may develop as well as some discoloration of the injection site ( thrombophlebitis ). This may require further surgical treatment .
Allergy to drugs used may cause an anaphylactic reaction resulting in paralysis , brain damage , or death .
Cardiac arrest or stroke . Other :____________________________________
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