Diagnosis: After careful oral examination, my periodontist has advised me that I require a soft tissue (gum) graft. Recommended treatment: In order to treat my condition my periodontist has recommended that my treatment include gum grafting surgery. Gum tissue will be harvested from your mouth (or donor tissue may be utilised) and placed at the deficient site. I understand that without treatment, this condition may cause further recession of the gum. 

Expected benefits: The purpose of gum grafting surgery is to to increase the zone of keratinised tissue and increase gingival attachment; complete root coverage may not be possible. This reduces the likelihood of further gum recession. 

Primary risks and complications: I understand a small number of patients do not respond successfully to gum graft surgery. Each patient's condition is unique and long term success may not occur. In some instances, soft tissue grafts may fail and additional procedures are required to achieve the desired outcome. This is part of the treatment and there is no additional cost.

I understand that complications may result from the surgery, drugs, and anaesthetics. These complications may 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 contro

• lPost surgical infectionTransient or permanent numbness of the lip, tongue, teeth, chin or gum

• Restricted ability to open mouth

• Referred pain to the ear, neck or head.

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

• Allergic reactions

• Injury to teeth

• Accidental swallowing of foreign objects

• Delayed healing

• Impact on speech

I understand that if I smoke I have an increased risk of the above complications. 

I have been informed and understand that there may be considerable post operative discomfort for 7-14 days, particularly at the harvest site. It is recommended not to plan anything important, and avoid swimming or heavy exercise for the next 2 weeks following the procedure. 

Alternatives to suggested treatment: I understand the alternative to gum grafting procedure is no treatment with possible advancement of my condition, which may result in premature loss of teeth.

No warranty or guarantee: It is understood that although good results are expected, they cannot be and are not implied, guaranteed, or warrantable. There is also no guarantee against unsatisfactory or failed results. If additional procedures are required to achieve the desired outcome, there is no additional cost. 

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 t he gum 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 gum 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.