Diagnosis: After careful oral and radiographic examination, my periodontist has advised me that a biopsy of the lesion is required to determine its histologic nature.

Recommended treatment: The purpose of this procedure is to remove a portion or entirety of the lesion so that a sample can be sent for histologic examination and assessment. Pending on the nature of the lesion, a further procedure may be required to remove the entire lesion.

Alternatives to suggested treatment: I understand that the alternative to biopsy is no treatment.

Sedation: Please speak to your treatment coordinator if this is something you wish to discuss further as this requires to be arranged prior to your procedure date, with a minumum of 24 hours notice.

I understand that if I take oral sedation, I will need a driver to and from my appointment and that I should not operate any heavy equipment/machinery for 24 hours following the use of oral sedation.

Primary risks and complications: I understand there can be complications of the biopsy procedure, drugs and anaesthesia including, but not limited to:

• Pain, swelling and post-operative discolouration of the face, neck and mouth

• Scarring, delayed healing

• Increase in gap between teeth and/or increase in length of tooth due to removal of lesion encompassing gum around tooth

• Bleeding which might require more advanced techniques to control

• Post surgical infection

• Transient or permanent numbness of the lip, tongue, teeth, chin or gum

• Restricted ability to open mouth. 

• Impact on speech

• Allergic reactions

• Injury to teeth, nearby blood vessels, salivary glands and ducts

• Limitation of jaw function and stiffness of jaw and facial muscles

• Referred pain to the ear, neck or head

• Post-operative, unfavorable reactions to drugs, such as nausea, vomiting and allergies

• Accidental swallowing of foreign objects

I understand that if I smoke I have an increased risk of the above complications. The exact duration of any complication(s) can not be determined, and they may be irreversible.

Payment Terms: I understand the proposed treatment plan estimation which has been presented to me as a written treatment plan outlining the required appointments, time frames, item codes and the fees associated with my treatment. 

I understand all appointments are to be paid in full on the day of the procedure, and I will be mindful of any daily bank card limits I may have, thus ensuring full payment can be made. 

I understand that if I wish to make payment via direct deposit that I will contact my treatment coordinator at least two days prior to my appointment, ensuring the funds have cleared before the commencement of my appointment.

I am aware that a HICAPS terminal is not available on site and I will claim any benefits that I may be entitled to directly from my health fund.

Patient Consent:

I have been fully informed of the nature of the biopsy, the risks and benefits, the alternative treatments available and the necessity for follow up care. I have had an opportunity to ask any questions I may have in connection with the treatment and discuss my concerns with my periodontist. I hereby consent to the biopsy as presented to me during consultation and in the treatment plan. 

I understand that during the procedure, conditions may become apparent which warrant additional or alternative treatment for my best interest, which I will be informed of. This may involve additional costs that may not have been outlined in the provided treatment plan.

I Understand the success of surgical procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, adequate oral hygiene, and medications that I may be taking. To my knowledge I have reported to my periodontist any prior drug reactions, allergies, diseases, symptoms, habits or conditions that in any way relate to this surgical procedure.

I have agreed to follow the post-operative instructions and to report to all follow up appointments.

Please note, due to the sterile environment, no family or friends are permitted chairside at the time of the procedure.

By providing my signature, I certify that I have read and fully understand this document and that all my questions have been answered to my satisfaction.