Oral Surgery Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record #: _______________

Procedure Details

Proposed Surgical Procedure(s): ________________________________________________ Site(s): _____________________________________________________________________

Acknowledgment of Understanding

I, the undersigned, hereby acknowledge that Dr. _________________ has explained to me:

1. The nature and purpose of the proposed procedure(s)
2. Reasonable alternatives to the procedure(s)
3. The potential risks, complications, and benefits

Specific Risks and Complications

I understand that the following risks may occur:

• Swelling, bruising, and temporary pain
• Post-operative bleeding
• Infection requiring additional treatment
• Injury to adjacent teeth or structures
• Temporary or permanent numbness
• Sinus complications (upper jaw procedures)
• TMJ (jaw joint) complications
• Need for additional procedures

Anesthesia Authorization

Type of anesthesia planned: ☐ Local ☐ Sedation ☐ General

I understand the risks associated with anesthesia, including:

• Allergic reactions
• Respiratory complications
• Cardiovascular complications

Financial Agreement

I understand that:

• My insurance may not cover all costs
• I am responsible for any uncovered charges
• Payment arrangements must be made prior to treatment

Signatures

Patient/Guardian Signature: ___________________________ Date: __________

Witness Signature: __________________________________ Date: __________

Doctor Signature: ___________________________________ Date: __________

Interpreter (if applicable)

Interpreter Name: ___________________________________ Signature: _________________________________________ Date: __________