Healthcare Oral Surgery Consent Form

HEALTHCARE ORAL SURGERY CONSENT FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Do you have a bleeding disorder or take blood thinners?

Are you pregnant or breastfeeding?

Do you have a pacemaker, prosthetic joint, or implant?

Procedure and Anesthesia

Anesthesia / Sedation to be used (check all applicable):

Local anesthesia (injection)    IV sedation    General anesthesia    Nitrous oxide (laughing gas)

Risks, Benefits and Alternatives

The following describes material risks, potential complications, and benefits associated with the proposed oral surgery and anesthesia. It is not a complete list of all risks. Common risks include pain, swelling, bruising, bleeding, infection, delayed healing, bruising, stiffness, and temporary or permanent numbness or altered sensation of the lips, tongue, chin or gums. Less common but serious risks include severe infection, nerve injury resulting in persistent numbness or loss of motor function, fracture of bone, sinus perforation, adverse reaction to medications or anesthetic agents, hospitalization, stroke or cardiac events, and death.

Alternatives to the proposed procedure may include no treatment, medication only, alternative surgical approaches, and referral for a second opinion. Refusal or delay of treatment may result in progression of disease, increased pain, infection, loss of teeth, and more complex future procedures.

Authorization and Consent

I hereby authorize the surgeon and staff to perform the procedure described above and to administer such anesthesia and medications as are necessary for the performance of the procedure. I authorize the performance of additional procedures and amendments to the planned procedure if, during the operation, such procedures are deemed necessary for my health and well-being. I acknowledge that no guarantees have been made to me as to the results of the procedure.

I consent to the administration of blood or blood products should they be medically indicated during or after the procedure.
I authorize blood/blood products if necessary

I consent to clinical photography, radiographs and recordings related to my care for medical documentation, diagnosis, treatment planning and education, understanding that identifying information will be protected and that images may be used for teaching unless I indicate otherwise.
I consent to clinical photography and recordings

I understand that I may withdraw my consent at any time prior to the administration of anesthesia or commencement of the procedure by notifying the provider. Withdrawal of consent after anesthesia or after commencement of surgery may have medical consequences and should be discussed with the provider.

HIPAA / Privacy Acknowledgment

By signing below, I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights regarding my health information and that I may request restrictions or amendments as provided by law.

I acknowledge receipt of the Notice of Privacy Practices

Authorization Expiration

This authorization will remain in effect until:

Acknowledgment and Certification

I certify that I have read (or had read to me) the above information, that the procedure, risks, benefits and alternatives have been explained to my satisfaction, and that all of my questions have been answered. I understand the nature of the proposed treatment and give my informed consent to the procedure and related care described in this form.

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