Consent Form – Extraction/Socket Preservation Bone Grafting
Part 1 – Patient Doctor Information Date:_____________
Patient Name: _________________________________________
Doctors Name: ________________________________________
In order for me to make an informed decision about undergoing a procedure, I should have certain information about the proposed
procedure, the associated risks, the alternatives and the consequences of not having it. The Doctor has provided me with this
information to my satisfaction. The following is a summary of this information. This form is meant to provide me with the information.
I need to make a good decision; it is not meant to alarm me.
Part 2 – Details of consent
Recommended treatment: Extraction and socket preservation #
My Doctor has recommended that a tooth or several teeth be extracted and immediate bone grafting be done to preserve the bone contour and allow future
placement of dental implants.
I have been informed and understand that occasionally there are complications of this procedure including, but not limited to:
- Pain and/or swelling
- Bleeding, bruising and/or discoloration of the face, usually of a temporary nature
- Infection that may adversely affect the new bone and require further treatment
- Limitation of jaw function
- Numbness and tingling of the lip, chin, gums, teeth, check and palate
- Post-operative unfavorable reactions to drugs, such as diarrhea, nausea, vomiting and allergy
Bone graft materials for socket preservation
- Autogenous bone (patient’s own bone)
- Alloplastic/Allogeneic bone (Synthetic/Derived from the bone bank)
My Doctor has explained the following medically acceptable alternatives:
- Extraction without immediate bone grafting
- No treatment
- Local anesthesia only
- Local anesthesia with Intravenous (IV) sedation
Anesthetic risks include discomfort, nausea/vomiting, dizziness and allergic reactions. There may be inflammation at the site
of an intravenous injection, which may cause prolonged discomfort and may require special care.
During the course of the procedure, my Doctor may discover other conditions that require an extension of the planned procedure,
or a different procedure altogether. I request that my Doctor performs the procedures that he thinks are better to do at this
sitting rather than later on.
My Doctor will give his best professional care toward accomplishment of the desired results. The substantial and frequent
risks and hazards of the proposed procedure are: The graft material not incorporating enough into the jaw, requiring other prosthetic measures.
Part 3 – My Responsibility
I agree to cooperate completely with my Doctor’s recommendations while under his care. If I don’t fulfill my responsibility,
my results could be affected. Smoking increases the risk of post-operative complications. Therefore, my Doctor has recommended
that I stop smoking two weeks prior to the scheduled surgical procedure and up to eight weeks following the completion of the procedure.
Success requires my long-term personal oral hygiene, mechanical plaque removal (daily brushing and flossing), completion of recommended
dental therapy, regular follow-up appointments and overall general health.
I have provided as accurate and complete medical and personal history as possible, including those antibiotics, drugs, medications, and foods
to that I am allergic. I will follow any and all instructions as explained and directed to me, and permit all required diagnostic procedures.
I have had an opportunity to discuss my past medical and health history including any serious problems and/or injury with my Doctor. Smoking may
adversely affect extraction site healing and cause failure of the bone graft
Necessary Follow-up Care and Self-Care
Natural teeth and appliances should be maintained daily in a clean, hygienic manner. I should follow post-operative instructions given after
surgery to ensure proper healing. I will need to come for appointments following the procedure so that my healing may be monitored and so that
my Doctor can evaluate and report on the outcome of the surgery upon completion of healing.
Part 4 – Miscellaneous
I know the fee that I am to be charged. As a courtesy to me, the office staff will help prepare the insurance claims should I be insured. However,
the agreement of the insurance company to pay for medical expenses is a contract between the insurance company and myself and does not relieve my
responsibility to pay for services provided. Some and perhaps all of the services provided may not be covered or not considered reasonable and customary
by my insurance company. I am responsible for paying all co-pays and deductibles at the time services are rendered.
Part 5 – Signature
I have read and understand this form. I have been encouraged to ask questions, and am satisfied with the answers. I have read this entire form.
I give my informed consent for surgery and anesthesia.
Someone at my Doctor’s office has explained this form, my condition, the procedure, how the procedure could help me, things that can go wrong,
and my other options, including not having anything done. I want to have the procedure done.
I authorize my Doctor to perform the procedure listed in the title above.
I know that I am free to withdraw from treatment at any time.
Patient signature: ____________________________ Date: _____________
Patient guardian: ____________________________ Date: _____________
If not the patient, what is your relationship to the patient? _________________________
I have explained the condition, procedure, benefits, alternatives, and risks described on this form to the patient or representative.
Doctor: _____________________________ Date: _____________