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Authorization for Oral Surgical Treatment

Oxford Family Dental

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Office Location

#3120-1971 Lougheed Hwy
Port Coquitlam, B.C., V3B 0K2

Email Us

info@oxfordfamilydental.com

Authorization for Oral Surgical Treatment

 

I further affirm that I have been advised of alternative treatments to this procedure and that the specific risks and complications of the procedures have been explained and questions answered to my satisfaction.

Specific surgical risks or complications discussed with me have included:

  1. Postoperative infection
  2. Dry socket
  3. Postoperative swelling and bleeding
  4. Pain and limitation of mouth opening
  5. Temporary or permanent injury to nerves providing sensation to the lips, face and tongue
  6. Damage to adjacent teeth or appliances
  7. Sinus infection or opening into the mouth

I also consent to the administration of anesthetics deemed necessary by the treating Dentist/Surgeon.

Clear Signature
Clear Signature

Procedure in cases of minors or incompetent persons:

  1. No parent signature is required for minors aged 16-19 who are supporting themselves.
  2. A minor aged 16-19 inclusive may give his or her consent of any treatment if the practitioner has:
    1. Made a reasonable effort to obtain consent of the parent or legal guardian
    2. The minor has requested that the parent or guardian is not to be notified or there is no parent/guardian and if one other practitioner has provided written information that the treatment undertaken is in the best interest of the continued health and well being of the minor aged 16-19.
  3. In all cases a minor under the age of 16, the consent of a parent or guardian must be obtained.  This shall be necessary in emergencies.  (see below)

If the patient is unable to sign, the following persons may sign on his or her behalf: Parent, adult sister or brother, son or daughter over age 19, and any other adult relations willing to assume all responsibility

CONTACT US

Call The Office

+1 (604) 942-1006

Office Location

#3120-1971 Lougheed Hwy
Port Coquitlam, B.C., V3B 0K2

Email Us

info@oxfordfamilydental.com

Oxford Family Dental

Oxford Family Dental

+1 (604) 942-1006

Info@oxfordfamilydental.com

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