I have been informed and afforded the time to fully understand the purpose and nature of the bone graft surgery procedure. After thorough examination of my mouth, my doctor has given and explained alternatives to treatment which I have considered, and have decided on a bone graft.

I understand that if nothing is done any of the following could occur: bone disease, loss of bone, inflammation of gum tissue, infection, sensitivity, tooth mobility requiring extraction, temporomandibular joint problems, headaches, referred pains to the neck and facial muscles, and tired muscles when chewing. I am also aware that a bone graft or implant placement may not be possible at a later date due to changes in my oral or medical conditions.

I am aware that in some instances bone grafts fail and must be removed with the possibility of requiring corrective surgery. Lack of adequate bone growth into the bone graft replacement material could result in failure. The practice of dentistry is not an exact science and I understand that no guarantees or assurances regarding the outcome of the results of surgery can be made. If the bone graft fails I understand that alternative prosthetic measures may have to be considered or additional bone grafting may be necessary.

I understand that excessive smoking, alcohol or blood sugar may affect gum healing and may limit the success of the bone graft. I agree to follow my doctor’s home care instructions and to have regular examinations as instructed.

I agree to the following procedures if they are deemed necessary by my doctor:

Autogenous graft – transplants bone from one region to another. Allograft – transplants bone from one individual to a genetically non-identical individual of the same species. All allografts are approved by the FDA and Tissue Bank. Alloplast – implantation of synthetic/chemically derived bone substitutes or membranes.

I request and authorize medical/dental services for myself, including bone grafts and other surgery.

I fully understand the contemplated procedure, surgery, and treatment conditions that may become apparent which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I approve any modifications in design, materials, or care, if felt this is for my best interest.

If an unforeseen condition arises in the course of treatment which requires treatment in addition to or different from that now contemplated, I further authorize and direct my doctor, associate or assistant, to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the bone graft procedure.