CONSENT FOR SINUS LIFT OPERATION AND ANY OTHER GRAFTING Permission is granted to download, print or otherwise copy this form for your personal use. I, , hereby authorize and request Dr. _____________________ and any other agent or employees of and such assistants as may be selected by him to perform corrective surgery on my jaw (maxilla). The operation is planned to implant a bone substitute material, freeze dried demineralized bone and/or hydroxyapatite, into the floor of the sinus in the hope that new bone will be incorporated into the material so that an implant(s) might be placed. A second procedure will be needed to place the implant(s). It is hoped that the implants will become stable and act as anchors for fixed or fixed detachable bridges or dentures. Dr. _____________________ has explained that if the new bone does not incorporate into the synthetic material that alternative prosthetic measures will have to be considered. Dr. _____________________ has explained and described the operation to my satisfaction. It is understood that although good results are expected no guarantee that it will last for any specific period of time can be or has been given. I have been informed and understand that occasionally there are complications of surgery, drugs and anesthesia, including, but not limited to: 1. Pain, swelling and postoperative discoloration of face, neck and mouth. 2. Numbness and tingling of the upper lip, chin, gums, teeth check and palate, which may be transient, but may be permanent. 3. Infection of the bone that might require further treatment, including hospitalization and surgery. 4. Malunion, delayed union or non-union of the synthetic bone replacement material to normal bone, or lack of adequate bone growth into the synthetic material. 5. Bleeding which may require blood transfusions or other extraordinary means to control. 6. Limitation of jaw function. 7. Stiffness of facial and jaw muscles. 8. Injury to the teeth. 9. Referred pain to the ear, neck and head. 10. Postoperative complications involving the sinuses, nasal cavity, sense of smell, infraorbital regions, and altered sensations of the upper cheek and eyes. 11. Postoperative unfavorable reactions to drugs, such as nausea, vomiting and allergy. 12. Possible loss of teeth and bone segments. 13. Possible bruising and/or discoloration of the face, usually of a temporary nature. I further understand that I am to refrain from the use of alcohol or non-prescribed drugs during the treatment period. If sedation or general anesthesia is used I agree 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 given for my care. Initial_____ To Consent Library                                                                   Next Page