Name:

Patient’s Name ____________________________________
Montana Oral Surgery and Dental Implant Center
INFORMED CONSENT
ORAL AND MAXILLOFACIAL SURGERY
AND ANESTHESIA

You have the right to be informed about: your diagnosis and planned surgery; reasonable treatment
alternatives; their benefits and risks; and, to make a decision whether to undergo or forego this treatment.
This disclosure details the possible complications, however rare, that are inherent in the treatment of your
condition. Please consider this form carefully, as its execution, along with your discussion with Dr.
Fleischmann, is a confirmation that you understand the nature and purpose of the treatment, the known risks
associated with the treatment, and the feasible treatment alternatives; that you have been given an opportunity
to ask questions; and, that all of your questions have been answered in a manner satisfactory to you.
ALL SURGERIES ____________
1. Soreness and pain. Radiating pain to the ear, teeth, neck or head. Discomfort usually increases over the first three to five days. 2. Swelling, bruising, and restricted mouth opening during healing, especially when TMJ problems 3. Bleeding and oozing, usually controllable, but may be prolonged and require additional care. 4. Drug reaction or allergy. 5. Infection, possibly requiring additional care, including hospitalization and surgery. 6. Stretching, cracking, swelling or burn of the lips and corners of the mouth. 7. Laceration of gums and soft tissues of the mouth. Ulcerations of the soft tissues of the mouth 8. Swelling and asymmetry. Difficulty opening the mouth, chewing and/or swallowing. Rarely, 9. Poor healing may require additional surgery to close a defect. 10. Nausea or vomiting. Bed rest, and sometimes medications, may be required for relief. 11. Osteomyelitis of the jaws, which may require hospitalization, IV medication therapy or surgical resection. People taking bisphosphonate medications (Fosamax, Zometa, Boniva, Actonel, as well as others) for osteoporosis or bone cancer, osteonecrosis may ensue requiring long term following and possibly additionally surgery. ALL TOOTH EXTRACTIONS ___________
1. Dry socket and delayed healing causing discomfort. Deep gum pockets resulting in sensitivity 2. Loosening/ cracking of adjacent teeth, crowns and fillings. 3. Sharp ridges of bone and bone splinters, which may require additional surgery to remove bone sequestra and smooth the area. Tattooing of the gums or mucosa may also occur. 4. Retained tooth fragments. Occasionally root tips separate and are deliberately left in place to avoid injury to nearby vital structures. 5. Incomplete healing occasionally requiring additional surgery. LOWER JAW SURGERY (including lower wisdom tooth surgery) ___________
1. Numbness: Although rare, loss of sensory nerve function following tooth removal or surgery on the lower jaw is possible. The lip, chin, teeth, cheek, gums or tongue could thus feel numb (resembling an anesthetic injection). There may also be pain, loss of taste, other sensory alterations and change in speech. This could remain for days, weeks or rarely, permanently. Muscle weakness is extremely rare. 2. Jaw Fracture: While quite rare, jaw fracture is possible in difficult or deeply impacted teeth, or in removing cysts and tumors of the jaw. This usually requires additional treatment, including surgery and possible hospitalization. Jaw fracture may occur up to 2 months after wisdom tooth surgery if you attempt to eat rock hard foods such as hard candy.
UPPER JAW SURGERY (including upper extractions) ___________

1. Sinus involvement: Due to the close proximity of the tooth roots to the sinus and nasal
cavity, a sinus or nasal cavity opening, displacement of a tooth root into the sinus, or a
sinus infection, may result from surgery of the upper jaw. In such an event, you will be
required to follow a 2 week course of medications and specific instructions and follow up with
the doctor to ensure good healing. In some cases, additional surgery may be needed.
ANESTHESIA ______________

1. Local Anesthesia: Although extremely rare, adverse reactions to anesthetics can occur,
including pain, swelling, bruising, infection, nerve damage, itching and rash. Rare reactions include heart attack, stroke, brain damage and/or death. 2. Intravenous or General Anesthesia: Certain risks exist that, although uncommon, include nausea, vomiting, pain, swelling, inflammation, and / or bruising at the injection site. Extremely rare risks include nerve or blood vessel injury (phlebitis), allergic or unexpected reactions, laryngospasm, bronchospasm, pneumonia, heart attack, shock, stroke, brain damage and death. 3. Medications, drugs, anesthetics and prescriptions may cause drowsiness, disorientation and lack of awareness/ coordination, which would be increased by the use of alcohol or other drugs. Operating machinery, driving, using cutlery, handling flammable materials, and alcohol use should not be attempted within 36 hours of taking such medications.
PATIENT NAME: _________________________________________
I hereby authorize Dr. Fleischmann and the Montana Oral Surgery and Dental Implant Center staff
to perform the following procedure(s):
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
and to administer anesthesia. I understand that Dr. Fleischmann may discover other or different
conditions that may require additional or different diagnostic and therapeutic procedures from those
planned. I authorize him to perform such other procedures, tests and administrations, as he deems
necessary in his professional judgment, in order to complete my surgery. I have discussed my past
medical history with Dr. Fleischmann, having disclosed and not omitted all diseases, conditions,
past surgeries, medications, elixirs, remedies, tobacco, alcohol and drug use.
If I am having intravenous or general anesthesia, I testify that I have NOT HAD ANY FOOD
OR DRINK FOR SIX HOURS before my appointment. To do otherwise may be life-
threatening. I agree not to operate mechanical or motorized equipment, drive, use cutlery,
etc…., for the next 36 hours. A responsible adult will escort me home, and accompany me
during this time period. I agree not to operate vehicles or mechanical equipment while
taking prescription narcotic or sedative medications.

I understand that individual reactions to treatment cannot be predicted, and that if I experience any
unanticipated reactions during or following treatment, I agree to report them without delay to Dr. Fleischmann.
I have read and discussed the preceding with Dr. Fleischmann, and believe that I have been given information
sufficient to give my consent to the planned surgery. All my questions regarding this consent have been
answered fully and to my satisfaction. No warranty or guarantee has been made as to the result s or cure. I
certify that I speak, read and write English, and have read and fully understand this Informed Consent for
surgery, or, if I do not, I have had it translated so that I can understand the consent form.
___________________________________________
Patient’s Signature (or Legal Guardian)

I certify that the matters set forth above were explained to the patient, that the patient was given an opportunity
to ask questions, and that all questions were answered in a satisfactory manner.
___________________________________
Doctor’s Signature

Source: http://montanaoralsurgery.com/pdf/informedconsent.pdf