Consent for Surgery Form

This is my consent for Drs. Tyko, Rogers, and any other surgeons who are working with them to perform oral surgery.

I understand that there are risks in any treatment or procedure, and that such risks include, but are not limited to, the following:

1. Postoperative discomfort and swelling that may require several days of home recuperation.
2. Heavy or prolonged bleeding.
3. Injury to adjacent teeth or fillings, ligaments, muscles and jaw joint (TMJ).
4. Postoperative infection requiring additional treatment.
5. Stretching of the corners of the mouth with cracking or bruising.
6. Breakage of the jaw or restricted mouth opening for several days or weeks.
7. Leaving a small piece of root in the jaw when its removal would require extensive surgery.
8. Injury to nerves in the bone and tissues resulting in numbness or tingling of the lip, chin, gums, cheeks, teeth and/or tongue. This may persist for several months or, in some instances, permanently.
9. Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
10. If intravenous medication is used, soreness and/or discoloration at the injection site, or along the vein.

Medications, anesthetics and prescriptions may cause drowsiness, lack of awareness and coordination, which can be increased by the use of alcohol or other drugs; thus I agree not to operate any vehicles, hazardous devices or work until fully recovered from the effects of taking medications or drugs.

I agree to cooperate with the recommendations of Drs. Tyko, Rogers and their associates while I am under their care, realizing that any lack of cooperation could result in a less then optimum result.

I CERTIFY I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND AGREE TO THE PROPOSED TREATMENT.

Signature of patient or responsible party (Type Full Name):