Elaine

This is an example of a consent form. Be assured, if something goes wrong the doctor is not responsible.


The proposed surgery has been outlined for me in laymen's terms and possible complications and side effects have been discussed including ( but not limited to ):


___A.Objectionable scarring of the incision line, possibly requiring later revision.


___B.Postoperative swelling, discomfort, bruising of the area, bleeding, hematoma (blood clot) formation, and wound infection.


___C.Adverse or allergic reactions to medications oranesthesia causing multiple side effects, some of which may be serious.


___D.Foreign body reaction and (if used) rejection of implant materials.


___E.Malocclusion (change in bite) after surgery.


___F.Postoperative development of adhesions (scarring) within the joint space which may cause continued jaw dysfunction and decreased range of jaw movement or chewing difficulty.


___G.Facial muscle weakness, particularly of the forehead and eyelid, or inability to close the affected eye tightly, which is caused by injury to
motor nerves in the immediate surgical area. This weakness may be partial or total and is usually temporary, but may be permanent.


___H.Sensory nerve damage, numbness, or other sensory alterations which may be temporary or permanent.


___I.Ear problems, including infection of external, middle or inner ear, ringing in the ear, hearing loss or equilibrium problems.


___J.Freys Syndrome


___5.I understand that additional treatment may be necessary post operatively, including physical therapy, splint therapy, reconstructive dentistry,
orthodontics, jaw repositioning surgery, removal of certain fixation devices, or further TMJ surgery including total joint replacement, bone grafts, and
arthroscopy.


___6.I understand that this is complex surgery, and there can be no guarantee of complete resolution of my present symptoms or jaw dysfunction. Occasionally
there may be increased symptoms post operatively.


___7.I have been told of my option of a second opinion regarding this procedure from a qualified professional.
___8.Recognizing that during surgery some unforeseen condition may be discovered that might necessitate a change in approach or different procedure from those
explained above, I authorize Dr. ****o perform such
procedures as are necessary and advisable in the exercise of his professional
judgment.


___9.I understand that general anesthesia will be used for my surgery and that there is risk of serious bodily injury inherent in such anesthesia, including
death. I have been told not to have any food or drink for 8 hours prior to my anesthetic and that CONSUMING FOOD OR DRINK BEFORE INTRAVENOUS GENERAL ANESTHESIA MAY CAUSE SERIOUS COMPLICATIONS OR DEATH!


___10.I have discussed my past medical history with my doctor and have disclosed all diseases and medications, including alcohol and drug use (past or
present).


___11.I agree to cooperate with the recommendations of Dr. ****,
realizing that lack of cooperation may result in a less than optimal result. I have not been given any warranty or guarantee as to the result of the
proposed procedure.


___12.I certify that I have had an opportunity to read and fully understand the terms within the and that all the above blanks were filled in prior to my
signing this form. All my questions have been answered to my satisfaction and I am willing to undergo the proposed surgery.