Diagnosis: After careful oral examination, my periodontist has confirmed I am a candidate for a frenectomy. A frenectomy is usually required for removal of an exceptionally short, thick, tight frenum, or which extends too far down along the gum. 

Recommended treatment: A frenectomy is a surgical procedure that removes or loosens a band of tissue that is connected to the lip, cheek or floor of the mouth.

Primary risks and complications: While this could be considered a low risk procedure, risks related with a frenectomy surgery might include post-surgical infection, bleeding, bruising, swelling, or pain. Risks related to the anaesthetics might include but are not limited to allergic reactions, accidental swallowing of foreign matter, facial swelling or bruising, pain, soreness or discoloration at the site of injection of the anesthesia.

Alternatives to suggested treatment: I understand that alternative to frenectomy surgery may include no treatment. 

No warranty or guarantee: Although good results are generally expected, they cannot be and are not implied, guaranteed, or warrantable. There is also no guarantee against unsatisfactory or failed results. In a small percentage of cases, a further procedure may be required.

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.

PATIENT CONSENT:

I have been fully informed of the nature of the frenectomy surgery, 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 frenectomy surgery as presented to me during consultation and in the treatment plan presented. 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.

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.

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.