Aziz Bohra, DMD, MS

13065 W. McDowell Suite A101, Avondale, Arizona 85392

623-935-0004

Consent for Biopsy Procedure

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A biopsy is a surgical procedure that requires a sample of tissue to be removed and sent to a pathological laboratory for microscopic study.

In your case the area of concern is:

It is necessary to remove the suspected tissue totally. If the biopsy report is suspicious, it may be necessary to return to the area to remove additional tissue to obtain a margin of safety,

OR

Remove only enough tissue to get a good enough sample leaving the remaining tissue behind. This is usually done when the lesion is large, it is suspected to be benign, or the removal of all of it at this time would be unnecessarily difficult. However, if the biopsy report is suspicious the entire lesion may have to be removed later.

1. I understand that a biopsy requires an incision in my mouth or on the skin, which will require stitches and sometimes the removal of bone tissue. It has been explained that there are certain risks associated with the surgery including (but not limited to):

  • Postoperative discomfort and swelling that may require several days at home recuperation.
  • Prolonged or heavy bleeding that may require additional treatment.
  • Post-operative infection that may require additional treatment.
  • Stretching of the corners of the mouth that may cause cracking and bruising, which may heal slowly.
  • Restricted mouth opening for several days, sometimes related to swelling and muscle soreness, sometimes related to stress on the jaw joints (TMJ),
  • Allergic reactions to medications, anesthesia, sutures, etc.
  • Injury to sensory nerve branches in the area of the biopsy which may result in pain, tingling or numb feeling in the lips, chin, tongue, cheek, gums, teeth or in the areas of the skin over the face. Usually this disappears slowly over several weeks or months, but occasionally the effects may become permanent.
  • If bone tissue is removed healing may take longer, and some complications may be more likely. The biopsy report may take longer to return due to special processing requirements.
  • An unforeseen opening into the sinus that may require additional treatment.
  • There is always the possibility of the lesion recurring in the same area even when it appears to be totally removed.
Initials

2. It has been explained to me that unforeseen conditions may be revealed which may necessitate an extension of the original procedure or a different procedure from that planned. I authorize Dr. Aziz Bohra to perform such additional procedures, if needed, in the exercise of good judgment.

3. I understand that I may be given appointments for long-term follow-up care with my general dentist after my biopsy even if the biopsy report is benign. I recognize the importance of returning for follow-up care which, if not done, may allow progression of my condition to a state requiring additional care or further surgery, as the lesion may recur. I agree to comply by regularly scheduling exams as instructed and to notify the office if I suspect a change in my condition.

4. I understand that a sample of my tissue will be sent to an oral pathology laboratory for microscopic study.

  • I understand the lab fee is not included in the cost of the biopsy fee at West Valley Periodontics. I will get a separate statement of services from the lab. The lab is a sole and separate entity and will bill my medical insurance accordingly.

5. I understand that no guarantee can be promised and I give my consent for treatment by West Valley Periodontics.

My signature below signifies that all questions have been answered to my satisfaction regarding this consent.

I fully understand the risks involved in the proposed surgery and anesthesia.

Patient's Signature:

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Guardian's Signature:

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Doctor Signature:

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Signature of Witness:

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