Stellar Smile Center

Informed Consent For Oral and Maxillofacial Surgery

Alternatives to Surgery: Risks to my health if the above procedure is not performed include but are not limited to:
Infection;
Cyst or tumor formation;
Periodontal (gum) disease; and
Increased risk for complications if removal is required at a later time.

Possible Complications which have been discussed with me include but are not limited to:
1. Injury to the nerves, to the lower lip, and tongue causing numbness which could be permanent;
2. Bleeding and/or bruising which may be prolonged;
3. Dry socket;
4. Involvement of the sinus above the upper teeth;
5. Infection;
6. Decision to leave a small piece of root in the jaw when its removal would require extensive surgery and increased risk of complications;
7. Injury to adjacent teeth or fillings; and
8. Unusual reaction to medications given or prescribed.

I understand that a perfect result cannot be guaranteed. If any unforeseen conditions arise during the procedure, I request and authorize the doctor to do whatever he deems advisable to correct the condition.

I agree to cooperate completely with Marie Jackson, and will follow postoperating instructions to the best of my ability for my own comfort and safety. I have had the opportunity to ask questions concerning these procedures.

(You May Refuse to Sign This Acknowledgement*)
Surgical removal of tooth/teeth number(s):
Additional Allergy Complications:
Date:
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