CONSENT for Oral/Dental Surgery

I have been informed during my consultation about the nature of my proposed treatment including the nature of surgery, risks of treatment, restorative phase of treatment, requirements and limitations of follow-up care, costs and about alternatives to the treatment, including no treatment.

I also have been informed if having oral sedation no food or drink 2 hours or if having IV sedation, I should not eat or drink from midnight the night before. I need to wear loose clothing, dark short sleeves, no contact lenses and remove all piercing in and around the mouth.
No medications to be taken morning of surgery with the exceptions of :

Post - operative Follow-up Care

I understand and agree that I must return for postoperative care and evaluation as outlined by Dr. Belsito. I understand that excessive smoking and alcohol may slow or affect the healing and success of surgery. Dr. Belsito has explained to me that there are certain normal sequellae (after effects) inherent in any oral surgery and may include some, none or all of the following:
-post-operative discomfort and swelling that may necessitate several days of home recuperation
-post-operative bleeding/infection that may require additional treatment
-insult to adjacent teeth/fillings
-stretching of the corners of the mouth that may result in minor carcking/bruising
-restrictive mouth opening for several days/week
-bruising skin/gums
-decision to leave of small piece of root when it's removal would require extensive surgery
-delayed healing with accompanying pain (dry socket)
I agree to follow Dr. Belsito's home care instructions.

Sedation

I agree to the type of sedation as determined by Dr. Belsito. I agree not to operate a motor vehicle or hazardous device and refrain from legal/financial decisions for at least 24 hr. or more until fully recovered from the effects of the sedative drugs given for my care.

Medical History

To my knowledge, I have given an accurate of my physical and mental health history. I have reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust and also any blood or body disease, gum or skin reactions, abnormal bleeding or any other conditions related to my health.

Dr. J.A.Belsito BSc,DDS,FAGD,FADI,FACD,Cert. IV sedation