I hereby authorize Dr. Jessica T. Wertz and/or Dr. Michael J. Wertz and/or Dr. Kim Tran-Wertz and whomever he/she may designate as his/her assistants, to perform upon me the diagnostic procedures and treatment necessary for proper dental care and if any unforeseen condition arises in the course of these designated operations and/or procedures calling, in their judgement, for procedures in addition to or different from those now contemplated, I further request and authorize him/her to do whatever he/she deems advisable.
I consent to the Dental Treatment plan after having been advised of the alternate plans of treatment available, the known material risks of the treatment to be used and the consequences if this treatment were withheld.
I am informed and fully understand that inherent in any type of surgery are certain unavoidable complications. In oral surgery, the most common of these complications include post-operative bleeding, swelling or bruising, discomfort, stiff jaws, loss of loosening of dental restorations. Less common complications can include infection, loss or injury to adjacent teeth and soft tissues, nerve disturbances (e.g. , numbness in mouth and lip tissues), jaw fractures, sinus exposure and swallowing or aspiration of teeth and restorations and small root fragments remaining in the jaw which might require extensive surgery for removal.
I further consent to the administration of local or general anesthesia, antibiotics, analgesics of any other drugs that may be deemed necessary in my case and under that there is a slight element of risk inherent in the administration of any drug or anesthesia. This risk includes adverse drug response (e.g., allergic reactions). cardiac arrest and aspiration; and thrombophlebitis (e.g., irritation and swelling of a vein), pain, discoloration and injury to the blood vessels and nerves which may be causes be injections of any medications or drugs.
A more complete explanation of all complications of surgery and anesthesia is available to me upon my request from the Doctor.
I realize that in spite of the possible complications, my contemplated surgery/treatment is necessary and desired by me. I am aware that the practice of dentistry and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the operation of procedure.
I realize that is is mandatory that I give as accurate and complete medical and personal history as possible, follow any and all instructions as directed and permit prescribed diagnostic procedures.
