Please read carefully and ask your dentist if you have questions regarding any of the following.
1. I have been informed, and I understand the purpose, of the bone graft procedure.
2. I understand that there may be risks and complications of any procedure including swelling, bruising, pain, bleeding, infection, altered sensation (usually numbness at the donor site), allergic reaction or other adverse reactions to medications or materials used during or after the procedure.
3. I understand that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a bone graft; and that the bone in its healing process remodels and there is no method to predict the final volume of bone, thus additional grafting may be necessary.
4. It has been explained to me that, in rare instances, bone grafts fail and must be removed. Lack of adequate bone growth into the bone graft replacement material could result in failure. No assurances or guarantees as to the outcome of the results of treatment or surgery can be made. I am aware that should the bone graft surgery fail, it may require further corrective surgery or the removal of the bone graft with possible corrective surgery associated with removal. Should the bone graft fail, I understand that alternative non-surgical prosthetic measures may have to be considered.
5. I understand that smoking or high blood sugar (diabetes) may affect gum healing and may limit the success of the bone graft. I agree to follow doctors home care instructions. I agree to report to my doctor for regular examinations as instructed.
6. To my knowledge, I have given an accurate report of my health history. I have also reported any unusual reaction to drugs, anesthetics, food, insect bites, pollen or dust; any blood or body diseases; gum or skin reactions, abnormal bleeding, or any other conditions related to my health.
7. I request and authorize medical/dental services for me, including bone grafts and other surgery. I fully understand that during and following the contemplated procedure, surgery, or treatment, conditions may become apparent which warrant in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve modifications in design, materials, or care, if it is felt this is for my best interest, including the decision not to proceed with the bone graft.
I have reviewed the above information, and have had the opportunity to have any questions/concerns addressed. Based on the information presented by my doctor(s) regarding my diagnosis, the proposed treatment, the treatment alternatives, and the associated risks and complications of such treatment, I request that you perform the planned surgical treatment.