General Consent for Surgery and Anesthesia
Patient’s Name _________________________________________________ Date ________________
I hereby authorize Dr.__________________________ and staff to perform the following procedure:
And to administer the anesthesia I have chosen, which is: ____Local ____ IV Anesthesia
I understand that there are known consequences of surgery and the administration of drugs and anesthetics
Which include (but are not limited to): pain and discomfort, swelling, bleeding, bruising, and infection.
Changes in the bite or restricted mouth opening secondary to stress on the jaw joint (TMJ) may occur.
There is also the possibility of injury to adjacent teeth or other tissues of the face or mouth, bone/jaw
fractures, delayed healing, dry socket, or unexpected drug reactions or allergies.
With tooth extraction, I understand that there may be unexpected damage to adjacent teeth or fillings, sharp ridges or bone splinters that may require later surgery to smooth or remove, dry socket which will require additional care, or small fragments of tooth root which may be left in place to avoid damage to vital structures such as nerves or sinus.
Lower tooth roots may be very close to the nerve and surgery may result in pain or a numb feeling of the chin, lip, cheek, gums, teeth or tongue lasting for weeks, months, or may rarely be permanent. On upper teeth where roots are close to the sinus, a sinus infection may develop, a root tip may enter the sinus and/or an opening from the mouth to the sinus may occur which could require later medication or surgery.
ANESTHETIC RISKS include: discomfort, swelling, bruising, infection, and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) which may cause prolonged discomfort and/or disability, and may require special care. Nausea and vomiting, although uncommon, may be unfortunate side effects of IV anesthesia. Intravenous anesthesia is a serious medical procedure and, although considered safe, carries with it the rare risks of heart irregularities, heart attack, stroke, brain damage or death.
YOUR OBLIGATIONS IF IV ANESTHESIA IS USED
Because anesthetic medications cause prolonged drowsiness, you MUST be accompanied by a responsible adult to drive you home and stay with you until you are recovered sufficiently to care for yourself. This may be up to 24 hours.
During recovery time (24 hours) you should not drive, operate complicated machinery or devices, or make important decisions such as signing documents, etc.
You must have a completely empty stomach. IT IS VITAL THAT YOU HAVE NOTHING TO EAT OR DRINK FOR SIX (6) HOURS PRIOR TO YOUR ANESTHETIC. TO DO OTHERWISE MAY BE LIFE-THREATENING!
However, it is important that you take any regular medications (high blood pressure, antibiotics, etc.) or medications provided by this office, using only a small sip of water.
I understand that no guarantee can be promised, and I give my free voluntary consent for treatment. I realize that my doctor may discover conditions requiring different surgery from that which was planned, and I give my permission for those additional procedures that are advisable in the exercise of professional judgment.
My signature below signifies that all questions have been answered to my satisfaction regarding this consent and I fully understand the risks involved of the proposed surgery and anesthesia. I certify that I speak, read and write English.
Patient’s (or Legal Guardian’s) Signature Date
Doctor’s Signature Date
Witness Signature Date