CONSENT FOR GUIDED TISSUE AUGMENTATION 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 guided tissue augmentation procedure on my jaw. As previously explained to me, the purpose of treatment is to regenerate bone in my jaw, around a natural tooth or around a dental implant. 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 damaged areas of my mouth to a useful state may involve any of the following methods: synthetic augmentation material, bone grafting using human freeze dried demineralized bone, natural hydroxyapatite or my own donor 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 from 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 adjacent soft tissues; referred pain to the ear, neck and head. Other potential complications could include nausea, vomiting, allergic reaction, bruises, delayed healing, ulceration of the mucosa (gums or tissue), loss of the implant material or device through the mucosa. 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 office or hospital for my care. If so requested, I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me home after my discharge from surgery. I agree to cooperate completely with the recommendations of Dr. _____________________ while I am under his care, realizing that any lack of same could result in a less than optimum result. I have had an opportunity to discuss with Dr. _____________________ my past medical and health history including any serious problems and/or injury. Initial_____ To Consent Library                                                                   Next Page