9 Holly Hill Drive
Petersburg, Virginia 23805-2559

(804) 733-9490

FAX (804) 733-3564

10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460

INFORMED CONSENT

TO OUR PATIENT:

VIRGINIA STATE LAW REQUIRES THAT PATIENTS BE INFORMED OF POSSIBLE COMPLICATIONS, EVEN THOUGH RARE, WHICH CAN OCCUR FROM ANY SURGICAL PROCEDURE, INCLUDING PERIODONTAL SURGERY.

IT MUST BE UNDERSTOOD THAT THESE COMPLICATIONS ARE UNUSUAL AND EXTREMELY RARE. EVERY PRECAUTION WILL BE TAKEN TO PREVENT THEIR OCCURRENCE, AS WELL AS TO TREAT THEM SUCCESSFULLY SHOULD THEY OCCUR.

THESE RARE COMPLICATIONS INCLUDE: INFECTION, HEMORRHAGE, NUMBNESS SECONDARY TO NERVE PRESSURE, AND ADVERSE REACTIONS TO MEDICATIONS USED DURING OR FOLLOWING SURGERY.

ON OCCASION, IN ORDER TO REGENERATE LOST PORTIONS OF TOOTH SUPPORT, BONE GRAFTS AND BARRIER MEMBRANES MAY BE UTILIZED. BONE GRAFT SOURCES CAN BE FROM A LABORATORY SOURCE, A TISSUE BANK (HUMAN SOURCE) OR AREAS OF YOUR OWN MOUTH. BARRIER MEMBRANES ARE OFTEN USED WITH OR WITHOUT BONE GRAFTS TO AID IN REGENERATION. NONRESORBABLE MEMBRANE REQUIRE SUBSEQUENT REMOVAL.

PATIENTS SHOULD BE MADE AWARE THAT SURGICAL CORRECTION OF DISEASED GUM TISSUE AND BONE COMMONLY RESULTS IN SOME EXPOSURE OF ROOT SURFACES AND THE TREATED TEETH ARE FREQUENTLY SENSITIVE TO HEAT AND COLD FOR A PERIOD OF TIME FOLLOWING SURGERY.

I FULLY UNDERSTAND THE PRESCRIBED PROCEDURES AND AUTHORIZE THE DOCTOR TO UTILIZE THE MATERIALS AND TECHNIQUES THAT, IN HIS PROFESSIONAL JUDGMENT, HE DEEMS NECESSARY


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