Healthcare Tori Removal Consent Form

Healthcare Tori Removal Consent Form

Patient Information

Patient Name:

Date of Birth:

Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Do you have a bleeding disorder? Yes No

Are you taking anticoagulants (blood thinners)? Yes No If yes, specify:

Pregnancy or possibility of pregnancy? Yes No

Procedure Details

Provider / Surgeon:

Procedure to be performed: Excision / removal of oral torus located at: Palatal (torus palatinus) Mandibular (torus mandibularis) Both

Intended anesthesia/analgesia (select all applicable): Local anesthesia IV sedation / conscious sedation General anesthesia

Anesthesia Provider (if different):

Risks, Benefits, and Alternatives

The nature and purpose of the procedure, its anticipated benefits, and the reasonably foreseeable risks have been explained to me. The primary benefits are relief of mucosal irritation, improved prosthetic fit if applicable, and prevention of future mucosal trauma. The reasonably foreseeable risks include, but are not limited to:

• Postoperative bleeding, infection, and delayed healing.
• Altered sensation, numbness or paresthesia of adjacent mucosa or sensory nerves; this may be temporary or permanent.
• Need for additional surgical procedures if healing is unsatisfactory or if residual bone remains.
• Fracture of the mandible (rare) or compromise of adjacent tooth structures.
• Scarring, persistent pain, or recurrence of bony growths at the same site.
• Risks associated with sedation or general anesthesia, including cardiovascular or respiratory complications.

Alternatives to this procedure include no treatment, conservative management, or prosthetic modification. I have had the opportunity to ask questions and all questions have been answered to my satisfaction.

Consent and Authorizations

I authorize the surgeon and assistants to perform the described procedure and to use such anesthetic agents as deemed necessary. I consent to use of adjunctive measures, including local hemostatic agents, sutures, imaging, and medications for pain control and infection prevention.

I authorize the taking of clinical photographs, radiographs, and models for medical records and treatment purposes. I understand that pathological specimens removed may be retained or disposed of in accordance with standard practice.

I acknowledge that no guarantee has been made as to the results of the procedure and that individual healing varies. I understand I may withdraw consent at any time prior to the administration of anesthesia or start of the procedure.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice's privacy practices and understand that my protected health information may be used for treatment, payment, and healthcare operations. I authorize release of medical information to insurance carriers and other providers as necessary for care coordination and payment.

I have read (or have had read to me) this consent form, I understand the information provided, and I consent to the performance of the procedure described above.

Please confirm the following acknowledgments by checking each box:

I understand the nature and purpose of the proposed procedure.

Risks, benefits and alternatives have been explained to me.

I have had the opportunity to ask questions and they have been answered.

I consent to administration of anesthesia as indicated for this procedure.

Additional Notes / Special Instructions

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