CONSENT FOR JAW RECONSTRUCTION SURGERY Permission is granted to download, print or otherwise copy this form for your personal use. This is my consent for Dr. _____________________ or any other agents and such assistants as may be selected by him to perform a__________________ on my __________________ jaw, as previously explained to me. I also agree to the use of a local and/or general anesthetic, sedation and analgesia, depending upon the judgment of the doctor and anesthesiologist involved in my case. I understand that the reconstructive operations necessary to restore the denture supporting areas of my mouth to a useful state may involve any or all of the following methods: Skin grafting/ vestibuloplasty: a procedure to expose usable bone or grafted material and cover it with a graft. Bone grafting using rib or hip bone to build contour. Hydroxyapatite grafting: a synthetic bone substitute that may be used by itself or in combination with bone. I also consent to any other procedure deemed necessary or advisable to complete the planned operation. I have been informed and understand that occasionally there are complications of the surgery, drugs and anesthesia, including pain; infection; swelling; bleeding, that may be heavy or prolonged; discoloration; numbness and tingling of the face, mouth, lips, tongue, chin, gums, cheeks and existing teeth, which may be temporary or permanent; pain, numbness and phlebitis (inflammation of a vein) from intravenous and intermuscular injection; injury to and stiffening of the neck and facial muscles; change in occlusion (bite) or temporomandibular (jaw) joint difficulty; injury to, and/or devitalization nerve damage which may require a root canal) of any existing teeth; injury to adjacent soft tissues; referred pain to the ear, neck and head. Other potential complications could include nausea, vomiting, allergic reaction, bone fractures, bruises, delayed healing, sinus complications, opening from the sinus to the mouth, apparent facial changes, nasal changes, loss of bone height, ulceration of the mucosa (gums or tissue), loss of the implant material or device through the mucosa. I agree not to use alcoholic beverages and unprescribed drugs and have been advised to avoid contact activities, persons with known communicable diseases and water sports for six weeks. Medication, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs; thus I have been advised not to operate any vehicle, automobile or hazardous devices, or work, while taking such medications and/or drugs; or until fully recovered from the effects of same. I understand and agree not to operate any vehicle or hazardous device for at least twenty four (24) hours after my surgery or until further recovered from the effects of the anesthetic medication and drugs that may have been given to me in the Initial_____ To Consent Library                                                                   Next Page