Oral Surgery Treatment Agreement and Informed Consent

Patient Information

Name: _________________ Date of Birth: _________________ Chart Number: __________ Date: _________________

Procedure Information

Proposed Treatment: _______________________________________ Area of Treatment: ________________________________________

Agreement and Consent

1. Procedure Understanding

I understand that I will undergo the following oral surgical procedure(s):

• Primary procedure: [detailed description]
• Alternative treatment options discussed: [list options]
• Expected outcomes and recovery timeline

2. Risks and Complications

I acknowledge that I have been informed of potential risks, including but not limited to:

• Pain, swelling, and bruising
• Infection and bleeding
• Nerve injury and altered sensation
• Sinus complications (for upper jaw procedures)
• TMJ dysfunction
• Need for additional procedures

3. Anesthesia Consent

I consent to the administration of:

• □ Local anesthesia
• □ Conscious sedation
• □ General anesthesia

4. Post-Operative Care

I agree to:

• Follow all post-operative instructions
• Attend scheduled follow-up appointments
• Contact the office immediately if complications arise
• Take prescribed medications as directed

5. Financial Agreement

• I understand my financial obligations
• Insurance coverage has been explained
• Estimated out-of-pocket costs: $_______

Signatures

Patient/Guardian: _________________ Date: _________

Witness: _________________________ Date: _________

Surgeon: _________________________ Date: _________

Office Use Only

□ Copy provided to patient □ Scanned to EMR □ Insurance verification complete