Oral Surgery Authorization for Treatment Form

I, _________________________ (patient name), hereby authorize Dr. _________________________ and their surgical staff to perform the following oral surgical procedure(s):

Planned Procedure(s)

Acknowledgments and Consents

1. Nature of Procedure

   • I understand the nature and purpose of the planned procedure(s)
   • The proposed treatment has been explained to me in terms I understand
   • Alternative treatment options have been discussed

2. Anesthesia Authorization

   • I consent to the administration of: (check applicable) □ Local anesthesia □ Nitrous oxide/oxygen analgesia □ Intravenous sedation □ General anesthesia

3. Risks and Complications I acknowledge that the following risks have been explained to me:

   • Post-operative pain and swelling
   • Infection and bleeding
   • Nerve injury with possible permanent numbness
   • Sinus complications
   • Adjacent tooth or restoration damage
   • Jaw joint (TMJ) complications

4. Additional Procedures I understand that unforeseen conditions may require additional or different procedures from those explained.

Certification

I certify that I have read and fully understand this authorization, and all my questions have been answered satisfactorily.

Patient/Guardian Signature: ___________________________ Date: ___________

Witness Signature: __________________________________ Date: ___________

Doctor Signature: ___________________________________ Date: ___________

Emergency Contact Information

Name: ___________________________ Phone: ___________________________ Relationship to Patient: ___________________________