BONE GRAFT CONSENT FORM

I understand that bone grafting and barrier membrane procedures include inherent risks such as, but not limited to the following:

1. Pain: Some discomfort is inherent in any oral surgery procedure. Grafting with materials that do not have to be harvested from your body is less painful because they do not require donor site surgery, but post-operative pain is still likely. It can be largely controlled with pain medications and applying a cold compression to the surgical site.
2. Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile oral environment, for infections to occur post-operatively. At times these may be of a serious nature. Should severe swelling occur, particularly accompanied with fever or malaise, professional attention should be received as soon as possible.
3. Bleeding, bruising, and swelling: Some moderate bleeding may last several hours. If profuse, you must contact us as soon as possible. Some swelling is normal, but if severe, you should notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or so.
4. Loss of all or part of the graft: Success with bone and membrane grafting is high. Nevertheless, it is possible that the graft could fail. Despite meticulous surgery, particulate bone graft materials can migrate out of the surgery site and be lost. A membrane graft could start to dislodge. If so, the doctor should be notified. Your compliance is essential to assure success.
5. Types of graft material:Some bone graft and membrane material commonly used are derived from human or other mammal sources. These grafts are thoroughly purified by different means to be free from contaminants. Signing this consent form gives your approval for the doctor to use such materials according to his knowledge and clinical judgment for your situation.
6. Injury to nerves: This would include injuries causing numbness to the lips, the tongue, any tissues of the mouth, and/or cheeks or face. This numbness, which could occur, may be of a temporary nature, lasting a few days, a few weeks, a few months, or could possibly be permanent. This could be the result of surgical procedures or anesthetic administration.
7. Sinus involvement: In some cases, the root tips of upper teeth lie near the maxillary sinus. Occasionally, with extractions and/or grafting near the sinus, the sinus can become involved. If this happens, you will need to take special medications. Should sinus penetration occur, it may be necessary to later have the sinus surgically closed.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me.
• I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary and I release KAI LIFE Clinic, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.
• My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.