You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved, to proceed with treatment or not. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.
Before the procedure you will be asked to sign a form similar to the following:
I voluntarily request Ralph K. Zech, D.D.S., M.S., as my oral surgeon, and such associates, technical assistants and other health care providers as they may deem necessary, to treat my condition, which has been explained as:
Erupted or Impacted Teeth/Biopsy
I understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I voluntarily consent and authorize these procedures:
Surgical Extraction of Erupted or Impacted Teeth/Biopsy
I understand that my oral surgeon may discover other or different conditions which require additional or different procedures than those planned. I authorize my oral surgeon, his associates, technical assistants and other health care providers to perform such procedures which are advisable in their professional judgement.
I understand that no warranty has been made to me as to result or cure.
Just as there may be risks and hazards on continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medial, and/or diagnostic procedures planned for me. I realize that along with surgical, medical, and/or diagnostic procedures is the potential for infections, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also realize that the following risks and hazards may occur in connection with this particular procedure:
- Paresthesia (numbness of lips, cheeks, tongue and/or gums)
- Injury to adjacent teeth and / or fillings
- Thrombophlebitis (vein irritation)
- Jaw fracture.
- Sinus problems
- Muscle spasms
- Limited opening of jaws
- Discoloration of injection sites, face or jaws
- Small root fragments remaining in the jaw which could cause damage to adjacent structures upon removal
- Alveolitis (dry socket)
- Reduced effectiveness of oral contraceptives due to post-pop antibiotics
I understand that anesthesia involves additional risks and hazards but I request the use of anesthetics for the relief and protection from pain during the planned and additional procedures. I realize the anesthesia may have to be changed, possibly without explanation to me.
I understand that certain complications may result from the use of any anesthetic including respiratory problems, drug reaction, paralysis, brain damage, or even death. Other risks and hazards which may result from the use of general anesthesia range from minor discomfort to injury to vocal cords, teeth or eyes.
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 informed consent.
The undersigned understands and appreciates that the intention is to relieve me of the pain and suffering or to correct a disease or to eliminate a potential disease or pathologic state or aid in the restoration of function, that the benefits of the intended treatment far outweigh the potential complications as outlined above. It is in this spirit that I have voluntarily presented myself to them for such treatment, have signed this consent for treatment, and agree to save harmless my oral surgeon for any treatment that, regardless of their effort to insure satisfaction, may produce a less than perfect result.
I certify this form has been fully explained to me, that I have read it or have had it read to me, that the blank spaces have been filled in, and that I understand its content. I consent to the release of information about my case to involved treatment healthcare practitioners and to the person to whom I am released.