Tyler Kim DDS & Tat Chiang DMD

CONSENT FOR PROCEDURE

Patients Name:______Date:______

You are going to have a Sinus Lift procedure. Therefore, you or your guardian should fully understand the nature of the operation and the most common risks involved. is not an exact science and this consent form does not list all of the possible complications that can be associated with this procedure. In addition, the surgeon cannot guarantee the results of the Sinus Lift procedure(s). The surgical procedure requires incision and reflection of the tissues (), removal of bone to expose the sinus cavity, lifting of the sinus membrane, placement of a bone graft for the floor of the sinus, possible placement of a , and closure of the wound with stitches. Implants may or may not be placed at the same time as the sinus lift procedure. This operation will be followed by a degree of discomfort, swelling, nasal and/or sinus stuffiness and pain that will require five to ten days of recuperation. Complete resolution of all symptoms may take up to 3 weeks or longer.

Possible Complications Sinus Lift Include: (Please initial all blanks) _____1) Wound infection and/or sinus infection. _____2) Pain. _____3) Post-operative bleeding, nose-bleed. _____4) Soreness of the corners of the mouth. _____5) Discoloration (black and blue) of the face or jaws _____6) Temporary or permanent numbness of the gums, upper teeth and palate in the area of procedure. _____7) Loss of the bone graft. _____8) Exposure of the barrier membrane requiring another procedure for its removal. _____9) Development of an opening between the sinus and the mouth. _____10) Damage to teeth, fillings, and loss of teeth. _____11) Inability to place implants in the bone graft in the future. _____12) Development or worsening of jaw joint symptoms. _____13) Need for additional surgery. _____14) If intravenous medications are used, soreness and bruising at the injection site and soreness of the course of the vein. ____ 15) Bisphosphonate (Fosamax®, Actonel, ..) patient may be as risk for developing osteonecrosis of the jaw and dental treatments may increase that risk. _____16) Other ______

CONSENT I am aware that the practice of periodontal surgery and Dentistry is not an exact science, and I acknowledge that I have not been given or received any guarantees, as to the results to be obtained from the surgical treatment I am to receive.

______Patient’s or Legal Guardian Signature Date

______Doctor’s Signature Date

______Witness’s Signature Date