Informed Consent Form
Diagnosis: After a thorough oral examination, my child's periodontist has advised me that the revision of a frenum(s) in my child's mouth may help to restore anatomy, function, and/or possibly prevent commonly associated future problems.
Recommended Treatment: In order to treat this condition, my child's periodontist has recommended that a frenectomy be performed at the selected site(s). A soft tissue laser will be utilized. This very laser
is FDA approved for this soft tissue surgery and is an excellent tool to optimize treatment and recovery.
Principle Complications: I understand that a smooth recovery is expected, however, there are always associated risks that cannot be eliminated and may occur in a minority of cases. These complications include but are not limited to post-surgical bleeding, infection, swelling, pain, damage to adjacent structures such as salivary glands, nerve, muscle, and skin. A more common complication is reattachment of the frenum. Genetics also plays a strong role in healing, such as formation of scar, keloid, or overt fibrous tissue formation.
Follow Up: I am advised to return for a 1-week check, and a 6 week check to follow up on the proposed care. Photos may be taken with my permission.
Alternatives to Suggested Treatment: I understand that alternatives to a frenectomy include: no frenectomy, with the expectation that the frenum does not normally improve with age but may aggravate the surrounding tissues including the gums and teeth. Also, an alternative to a frenectomy by my periodontist is to seek the care of another health care professional, including but not limited to doctors of general dentistry, periodontics, oral surgery, ENT, and plastic surgery. The use of the laser itself can be deferred to more traditional instruments of care.
No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful. I do expect however that the doctor performs the surgery to the best of his ability.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT AND ALL MY QUESTIONS WERE ANSWERED
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