Diagnosis: After careful oral and radiographic examination, my periodontist has advised me that I require bone grafting surgery.

Recommended treatment: In order to treat my condition my periodontist has recommended the use of processed bone of animal or human origin, or bone that is taken from another area of my mouth, which will be used to repair the bony defect. I understand that local anaesthetic will be administered to me as part of the treatment and I have the option of sedation. There is a healing period of 3-6 months or more before planning for implant placement.

Expected benefits: The purpose of this procedure is to attempt the regrowth and preserve the bone in a specific site.

Primary risks and complications:  I understand that some patients do not respond successfully to dental implants, and in such cases, the implant may need to be removed. Because each patient's condition is unique, long term success may not occur.

I understand that complications may result from the implant surgery, drugs, and anaesthetics. These complications include, but are not limited to:

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

• 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

• Accidental swallowing of foreign objects

• Delayed healing

• Mal-union, delayed union, or non-union of the bone graft material to normal bone

• Lack of adequate bone growth into the bone graft replacement material

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

• Referred pain to the ear, neck or head.

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

• Damage to sinuses requiring additional treatment or surgical repair at a later date
  

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.

Alternatives to suggested treatment: I understand that alternatives to bone grafting surgery includes no treatment, and have been advised of the implications.

 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 due to individual patient differences; a periodontist cannot predict certainty of success. There exists the risk of failure, relapse, additional treatment, or worsening of my present condition including the possible loss of certain teeth or implants despite the best care.

Publication of records:  I authorise photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry. However my identity will not be revealed to the general public without my permission.

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.

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 bone grafting 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 bone grafting surgery 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.