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Patient Information

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Part 1 - Patient & Doctor Information

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 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

My doctor has explained the nature of my condition to me. Gum recession, or a predisposition to gum recession, causing tooth root exposure.
Procedure - Gingival grafting surgery
My physician has proposed the following procedure to treat or diagnose my condition: Gingival grafting surgery. This means: Transplanted tissue will be placed to partially or completely cover the exposed tooth root surface. The transplanted tissue is received from a donor site. An alternative tissue such as alloderm, a dermal matrix from a tissue bank, may be used.
Gum grafting involves the transplanting of a thin strip of gingiva from the palate (roof of the mouth) and sutures will be placed on the palate. The existing gum tissue around the teeth to be grafted will be excised back, and he transplanted gingiva from the palate will be sutured in place and the existing gum sutured over the graft tissue. The sutures on the palate fall out in about 2-3 days, and the sutures around the grafted tooth will fall off in about 3 to 4 weeks. About 1/3 of the time, about 3 to 4 months after the graft is done, it is necessary to "refine" the area like a scar revision, usually using a dermatology-type carbon dioxide laser.
My Dentist has explained the following medically acceptable alternatives to be: Monitoring for progressive recession, changing the way I brush my teeth. No treatment (The Likelihood of gum recession and subsequent jawbone loss around the effected teeth is higher with no gum graft than with a successful gum graft. There are studies that show the incidence of tooth loss is 6 times greater in individuals with untreated gum problems as compared to early treatment of gum problems). Also, I can seek specialized care somewhere else, or I can have nothing done.
Consequences of not having procedure
If I don't have the procedure, my condition may stay the same or even improve. However, it is the doctor's opinion that the proposed procedure is a better option for me. If I don’t have the procedure, the following may also happen; Continued gum recession.
Other procedures
During the course of the procedure, the doctor may discover other conditions that require an extension of the planned procedure, or a different procedure altogether. I request the doctor to do the procedures my doctor thinks are better to do at this siting rather than later on.
The 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; Tissue placed over the root may shrink back during healing, providing incomplete coverage of the exposed root surface and requiring a second procedure to fully cover the root. These are usually temporary. Uncommonly, these effects may persist. Uncommon risks also include: Tooth looseness, impact on speech, and accidental swallowing of foreign matter. A small number of patients (usually around 5% or so) do not have the graft "take". The usual causes are excessive shrinking of the graft tissue while healing the first couple of weeks, smoking, or the patient knocking the graft loose during the first week. So it might be necessary to do the graft over again after about 3 months to allow the surgical sites to heal up first. Usually, but not always, the 2nd graft will "take". Sometimes complications may result from the gingival graft surgery or from anesthetics/drugs. These complications include, but are not limited to post-surgical infection, bleeding, swelling, pain, facial brushing, translent (on rarest of occasions permanent) numbness of the jaw, lip, tongue, chin or gum, jaw joint pain or muscle spasm, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech, allergic reactions, accidental swallowing of foreign matter, and transient (on rarest of occasions permanent) increased tooth looseness, tooth sensitivity to hot, cold, sweet or acidic foods, The exact duration of any complication cannot be determined, and they may be irreversible.
Drugs, Medications, and Anesthesia Antibiotics, pain medication, and other medications may cause adverse reactions such as redness and swelling of tissues, pain, itching, drowsiness, nausea, vomiting, dizziness, lack of coordination, miscarriage, cardiac arrest, which can be increased by the effect of alcohol or other drugs, blood clot in the legs, heart, lungs or brain, low blood pressure, heart attack, stroke, paralysis, brain damage. Sometimes after injection of a local anesthetic, I may have prolonged numbness and/or imitation in the area of injection. If I use Nitrous Oxide, Atarax, Chloral hydrate, Xanax, or other sedative, possible risks include. but are not limited to, passing out, severe shock, and stopping breathing or heartbeat I will arrange for someone to drive me home from the office after I have received sedation, and to have someone watch me closely for 10 hours after my dental appointment to observe for side effects such as difficulty breathing or passing out.
No guarantee
The practice of dentistry and surgery is not an exact science. Although good results are expected, the doctor has not given me any guarantee that the proposed treatment will be successful, will be to my complete satisfaction, or that it will last for any specific length of time. Due to individual patient differences, there is always a risk of failure, relapse, need for more treatment, or worsening of my present condition despite careful treatment. Occasionally treated teeth may require extraction.

Part 3 - My Responsibility

I agree to cooperate completely with the doctor's recommendations while under his/her care. If I don't fulfill my responsibility, my results could be affected. Success requires my long-term personal oral hygiene, mechanical plaque removal (daily brushing and flossing), completion of recommended dental therapy, periodic periodontal visits (dental clinic care), regular follow-up appointments and overall general health.
There may be several follow-up clinical visits for the first year following surgery. It is my responsibility to see the doctor at least once a year for evaluation of implant performance and oral hygiene maintenance.
I have provided as accurate and complete medical and personal history as possible, including those antibiotics, drugs, medications, and foods to which 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 the doctor.
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. l 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.
I will not drink alcohol or take non-prescribed drugs during the treatment period. If sedation or general anesthesia is used I will not to operate a motor vehicle or hazardous device for at least 24 hours or more until full recovered from the effects of the anesthesia or drugs.
I will let the doctor's office know if I change my address so I can be contacted for any recalls.

Part 4 – Miscellaneous

I give permission for persons other than the doctors involved on my care and treatment to observe this operation (such as company representatives and dentists who are learning the procedure) and I consent to photography, filming, recording and x-rays of my oral and facial structures and the procedure, publication for educational and scientific purposes, provided my identity is not revealed. I give up all rights for compensation for publication of these records.
If teeth are removed during treatment, they may be retained for training purposes and then disposed of sensitively.
I know the fee that I am to be charged. I am satisfied with it and know that it does not include additional post-operative x-rays, injections or anesthetics that may later be necessary to correct any complications. As a courtesy to me, the office staff will help prepare and file insurance claims should I be insured. However, the agreement of the insurance company to pay for medical expenses is a contract between myself and the insurance company 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 and all costs that have not been paid for by my insurance within 45 days. Otherwise, all payments are due at the time services are rendered. All accounts not paid in full within 90 days shall accrue interest at the rate of 18% per year. I will be liable for all collection costs, including court costs and attorney fees.

Part 5 - Signature

I read and write English. I have read and understand this form. All blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any, were stricken before I signed. 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 the 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 Dr.
or his designee (referred to any other Dentists) to perform the procedure listed in the title above.
I know that I am free to withdraw from treatment at any time.
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If not the patient, what is your relationship to patient?
I have explained the condition, procedure, benefits, alternatives, and risks described on this form to the patient or representative.
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