Dental Surgery Please complete the following form to consent for your upcoming dental surgery. Consent for Dental Surgery I acknowledge and understand: The treatment to be performed by Dr. Kurt D. VanWinkle indicates that the procedure is needed to maintain a healthy periodontal condition Other forms of treatment or no treatment at all are options that have been explained to me Dr. VanWinkle and his staff have answered my questions to my satisfaction During the course of the surgery, treatment may need to be modified due to existing conditions that are only evident when the surgical site has been exposed. Therefore, fees may be incurred that were not initially treatment planned I consent to any additional or alternative procedures that may be deemed necessary in the judgment of Dr. Kurt VanWinkle Complying with surgical follow-up instructions is of most importance to the healing process. If you are a smoker, please know that smoking is very harmful to the mouth and can delay healing and affect the outcome of the surgery performed I have contacted my prescribing physician for instructions on stopping my blood thinning medications. Risks associated with periodontal treatment: Stretching of the corners of the mouth creating cracking and soreness Injury or damage to teeth near the area being treated Difficulty in opening the mouth for several days. Muscle and jaw joint (TMJ) soreness Post surgical infection that would require further treatment Prolonged numbness in the chin, lip, cheek, gums, or tongue. This may last for days or weeks. Although rare, permanent numbness is possible, especially with dental implant surgery. Patient Name(Required) First Last Who are you?(Required) Patient Spouse Parent Guardian Your Name(Required)Since you are not the Patient, please enter your name below. First Last Date(Required)Please enter today's date in mm/dd/yyyy format. Signature(Required)BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged.