Informed Consent

Robert K. Conlon DDS Kurt E. Bruksch DDS Adam M. Ozment DDS John J. Richard DDS Bryan J. VanOven DDSCrystal Lake: 815-459-5600 Lake Geneva: 262-248-8766 Huntley: 847-669-2900 Burlington: 262-763-8101

C&O 3008-1

Orthognathic Surgery

If you have any questions, please ask your doctor before initialing.

I have been informed and understand that occasionally there can be potential complications with the surgery, drugs, and/or anesthesia, including, but not limited to: pain, infection, swelling, bleeding that may be heavy or prolonged, potential need for a blood transfusion and the attendant risks thereof, discoloration, numbness, tingling, (sensory alteration) of the lips, tongue, chin, gums, cheeks and teeth (which may be temporary or permanent); pain, numbness, and phlebitis (inflammation of a vein) from intravenous, or intramuscular injection, injury to, or stiffening of the neck and facial muscles; altered adjacent facial muscle function for an indefinite time; unfavorable changes in the occlusion (bite), persistence or worsening of the pre-operative temporoman-dibular (jaw) joint status; injury to adjacent teeth or restorations; injury to adjacent soft tissues; or referred pain to the ear, neck and/or head. Other potential complications could include nausea, vomiting, allergic reactions, unfavorable bone fractures, bruises, delayed healing, sinus complication, opening from the sinus or nose into the mouth, nasoseptal deviation, unesthetic facial or nasal changes, facial asymmetry, the need for additional surgical procedures, loss of bone and/or teeth, non-healing of the boney segments, devitalization (nerve damage which may require a root canal) of teeth, relapse (dental and/or bony), injury to major or minor salivary glands, need for a bone graft, development of periodontal problems, visual problems, tear duct problems, vascular compromise, tissue necrosis, or the temporary or permanent limitation of jaw opening (decreased jaw opening), necessitating prolonged postoperative jaw physiotherapy (exercises, stretching).

It has been explained to me that this surgical procedure may involve the wiring of my teeth together. The inherent potential complications of that procedure have been explained to me, and I agree to carry wire cutters with me at all times during the time my teeth are wired together, in case of an emergency.

Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and coordina-tion, which can be made worse by the use of alcohol or other drugs. Thus, I have been advised not to operate any vehicle, automobile or hazardous devices, or work while taking such medications and/or drugs; or until fully recovered from the effects of same. I understand and agree not to operate any vehicle or hazardous device for at least twenty-four hours after my release from surgery or until further recovered from the effects of the anesthetic medications and drugs that may have been given to me in the office or hospital for my care. I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me home after my discharge from surgery.

Please initial each paragraph after reading

This is my consent for Dr. and/or any other oral and maxillofacial surgeon working with

him to perform: as previously explained to me, and/or other procedure deemed necessary or advisable to complete the planned opera-tion. I also agree to the use of a local and/or general anesthetic, sedation and analgesia, depending upon the judgment of the oral and maxillofacial surgeon and anesthesiologist involved in my case.

I agree to cooperate completely with the recommendations of Dr. while I am under his care, realizing that any lack of cooperation could result in a less than optimum result. I understand that the surgical phase of active treatment involves a minimum of four months of regular visits, elastic treatment, jaw exercises, and other activities.

I have had an opportunity to discuss with Dr. my past medical and health history including any serious problems and/or injuries.

I understand that certain anesthetic risks, which could involve serious bodily injury, are inherent in any proce-dure that requires a general anesthetic.

The fee for services has been explained to me and is satisfactory, and I understand there is no warranty or guarantee as to the result and/or cure and that my condition may return or become worse.

I have had an opportunity to read and fully understand the terms and words within the this consent form, all blanks or statements requiring insertion or completion were filled in, and inapplicable paragraphs, if any, were stricken, before I signed this form.

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Patient Name: Today’s Date: / /

Please continue to Page 2 of 2

If you have any questions, please ask your doctor before initialing.

I have been informed and understand that occasionally there can be potential complications with the surgery, drugs, and/or anesthesia, including, but not limited to: pain, infection, swelling, bleeding that may be heavy or prolonged, potential need for a blood transfusion and the attendant risks thereof, discoloration, numbness, tingling, (sensory alteration) of the lips, tongue, chin, gums, cheeks and teeth (which may be temporary or permanent); pain, numbness, and phlebitis (inflammation of a vein) from intravenous, or intramuscular injection, injury to, or stiffening of the neck and facial muscles; altered adjacent facial muscle function for an indefinite time; unfavorable changes in the occlusion (bite), persistence or worsening of the pre-operative temporoman-dibular (jaw) joint status; injury to adjacent teeth or restorations; injury to adjacent soft tissues; or referred pain to the ear, neck and/or head. Other potential complications could include nausea, vomiting, allergic reactions, unfavorable bone fractures, bruises, delayed healing, sinus complication, opening from the sinus or nose into the mouth, nasoseptal deviation, unesthetic facial or nasal changes, facial asymmetry, the need for additional surgical procedures, loss of bone and/or teeth, non-healing of the boney segments, devitalization (nerve damage which may require a root canal) of teeth, relapse (dental and/or bony), injury to major or minor salivary glands, need for a bone graft, development of periodontal problems, visual problems, tear duct problems, vascular compromise, tissue necrosis, or the temporary or permanent limitation of jaw opening (decreased jaw opening), necessitating prolonged postoperative jaw physiotherapy (exercises, stretching).

It has been explained to me that this surgical procedure may involve the wiring of my teeth together. The inherent potential complications of that procedure have been explained to me, and I agree to carry wire cutters with me at all times during the time my teeth are wired together, in case of an emergency.

Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and coordina-tion, which can be made worse by the use of alcohol or other drugs. Thus, I have been advised not to operate any vehicle, automobile or hazardous devices, or work while taking such medications and/or drugs; or until fully recovered from the effects of same. I understand and agree not to operate any vehicle or hazardous device for at least twenty-four hours after my release from surgery or until further recovered from the effects of the anesthetic medications and drugs that may have been given to me in the office or hospital for my care. I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me home after my discharge from surgery.

I agree to cooperate completely with the recommendations of Dr. while I am under his care, realizing that any lack of cooperation could result in a less than optimum result. I understand that the surgical phase of active treatment involves a minimum of four months of regular visits, elastic treatment, jaw exercises, and other activities.

I have had an opportunity to discuss with Dr. my past medical and health history including any serious problems and/or injuries.

I understand that certain anesthetic risks, which could involve serious bodily injury, are inherent in any proce-dure that requires a general anesthetic.

The fee for services has been explained to me and is satisfactory, and I understand there is no warranty or guarantee as to the result and/or cure and that my condition may return or become worse.

I have had an opportunity to read and fully understand the terms and words within the this consent form, all blanks or statements requiring insertion or completion were filled in, and inapplicable paragraphs, if any, were stricken, before I signed this form.

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Informed Consent for Orthognathic Surgery Cont ’d.

X / / Signature (Parent or Guardian, if minor) Date

X / / X / / Signature of Doctor Date Signature of Witness Date

“I have been advised of the risks of this surgery, the possible complications and the alternatives available to me. I have read the printed material on complications and side effects. I have been given an opportunity to ask questions about the surgery/anesthesia and have had my questions answered. I

am aware that potentially hazardous complications can occur if I have not followed preoperative instructions and that surgery or anesthesia could result in serious bodily injury. I am fully aware that a perfect result cannot be guaranteed. I certify that I speak, read and write English. By signing this

form I am freely giving my informed consent to the surgery.”

I hereby authorize Dr. Conlon/Bruksch/Ozment/Richard/VanOven and his staff to perform the following procedure(s):

C&O 3008-2