INDY SMILE GROUP • FOR OFFICE USE

Printable Consent Form

Indy Smile Group
Carmel • Fishers • North Indianapolis
Printable Paper Consent Form
For Manual Signature
Oral Surgery

ORAL SURGERY

Oral surgery includes procedures such as tooth extractions (including wisdom teeth), biopsies, removal of lesions, bone grafting, or other surgical interventions in the mouth and jaws.

DESCRIPTION OF TREATMENT

The area is numbed with local anesthesia (sedation or general anesthesia may be used in some cases). An incision may be made, bone or tissue removed or modified, and the site sutured. Post-operative instructions will be provided. Healing time varies by procedure.

BENEFITS

  • Relief from pain, infection, or other symptoms
  • Removal of diseased or problematic tissue/teeth
  • Preparation for further treatment (implants, orthodontics, etc.)
  • Improved oral health and function

RISKS AND POSSIBLE COMPLICATIONS

  • Pain, swelling, bruising, and discomfort
  • Bleeding
  • Infection
  • Dry socket (after extractions, especially lower wisdom teeth)
  • Injury to nerves (temporary or permanent numbness, tingling, or pain in lip, tongue, chin, or gums)
  • Damage to adjacent teeth, restorations, or sinus
  • Jaw fracture (rare, usually with impacted wisdom teeth)
  • Delayed healing or non-healing of bone (osteonecrosis, especially with certain medications)
  • Allergic reaction to medications or materials
  • Need for additional surgery or treatment

I understand that no surgical procedure is without risk and that complications can occur even with proper care.

ALTERNATIVES

  • No surgery (may lead to worsening symptoms or complications)
  • Alternative treatments such as medication or less invasive options (when applicable)
  • Referral to an oral surgeon or specialist

PATIENT ACKNOWLEDGEMENT

  • I understand the nature of the recommended surgical procedure and the expected healing process.
  • I have disclosed my full medical history, including medications (especially bisphosphonates or blood thinners), allergies, and pregnancy status.
  • I consent to the use of local anesthesia and any sedation or medications deemed necessary.
  • I agree to follow all pre- and post-operative instructions, including diet, activity, and medication use.
  • I understand the importance of not smoking or using straws after certain procedures.

PATIENT / GUARDIAN ACKNOWLEDGEMENT AND CONSENT

I have read (or had read to me) and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the proposed treatment. I voluntarily consent to the treatment described above.

PATIENT / GUARDIAN ACKNOWLEDGEMENT AND CONSENT

I have read (or had read to me) and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the proposed treatment. I voluntarily consent to the treatment described above.

Patient / Legal Guardian Signature
Print Name
Date
Relationship to Patient (if not patient)
PROVIDER CONFIRMATION

I have explained the nature, purpose, risks, benefits, and alternatives of the proposed treatment. The patient (or guardian) appears to understand the information and has had an adequate opportunity to ask questions.

Provider Signature
Print Name & Title
Date
Witness (optional)
Signature                                               Date
Indy Smile Group • Carmel • Fishers • North Indianapolis • This is a printable paper consent form for manual signature. A signed copy is retained in the patient record.

Optimized for Letter / A4 paper. Use your browser’s print dialog (Ctrl/Cmd + P) for best results.