Oral Surgery Consent Form * Denotes required field Patient name* Date of birth* Age* Status* Do you have or have you had any of the following? High Blood Pressure YesNo A heart condition YesNo Rheumatic Fever YesNo Verereal Disease YesNo Kidney-Diseasee YesNo Fainting history YesNo Thyroid Disease YesNo Liver Disease YesNo Rheumatism YesNo Asthma YesNo Anemia YesNo Diabetes YesNo Hepatitis YesNo Epilepsy YesNo Allergies YesNo Tonsillitis YesNo Glaucoma YesNo Hay Fever YesNo Tuberculosis YesNo Stomach Ulcer YesNo Sinus-Problem YesNo Clotting Disorder YesNo Nervous Disorder YesNo Bleeding Disorder YesNo Enlarged Adencids YesNo Do you have any allergies Penicillin YesNo Other antibiotic YesNo Are you taking medicine at present? YesNo Are you being treated by a Physician? YesNo If so, what? I hereby authorize Dr. Mia Anne Villanueva Perez and any other dentists of Teeth Hub Dental Clinic to perform the following treatment or surgical procedure , and I understand that this is an elective, urgent, or emergency procedure (circle one). I have been informed that the risks to my health if this procedure is not performed include, but are not limited to pain, infection, cyst formation, loss of bone around teeth causing their loss, and an increased risk of complications if surgery is postponed. I have been informed of any possible alternative methods of treatment should any exist, Further, I understand that there are certain inherent and potential risks in any treatment or procedure, and that in this specific instance, such risks may include the following: 1. Postoperative discomfort and swelling that may necessitate several days of home recuperation. 2. Restricted mouth opening for several days or weeks. 3. Heavy bleeding that may be prolonged. 4. Nausea and vomiting (usually associated with medications prescribed for pain). 5. Postoperative infection requiring additional treatment 6. Decision to leave a small piece of root in the jaw when its removal would require extensive surgery. 7. Damage to adjacent teeth, fillings, and crowns, 8 Stretching of the corners of the mouth with resulting cracking and bruising. 9, Change in occlusion and temporal-mandibular joint difficulty. 10. Prolonged drowsiness. 11. With surgery and extractions of the upper jaw, an opening into the maxillary nasal sinus or nose (a normal cavity situated above the upper teeth ) requiring additional surgery, 12. With surgery and extractions of the lower jaw, injury to the nerve underlying the teeth resulting in numbness or tingling of the lip, chin, gums, cheek, teeth and / or tongue on the operated side. This may persist for several weeks, months, or in remote instances, be permanent. 13. Breakage / fracture of the jaw. 14. Cardiac arrest, 15. Other: I consent to the administration of local anesthesia (Lidocaine, Articaine, Mepivacaine), nitrous oxide analgesia or oral sedation in connection to the procedure referred to above (circle all that apply)* Yes I certify that I have read the above and fully understand this consent for surgery, and that I understand that a perfect result cannot be guaranteed. If unexpected problems arise during the procedure, the doctor has my permission to do what is deemed necessary to correct the condition. Drugs given at the time of surgery for sedative purposes or control of pain following the surgery may cause drowsiness and a lack of awareness or coordination. If instructed to do so, | will not drive or perform hazardous chores until | have recovered from the effects of these medications. Yes, I agree with the following terms and condition.I do not agree on some of the terms and condition. (please contact us to address your concern)
