Consent For Gingivectomy/Frenectomy

Gingivectomy: A Gingivectomy/Frenectomy is a type of surgery used to remove excess tissue or to expose a tooth for orthodontic purposes and keep for the future. It involves not only removal of the tissue, but scaling and root planning of the affected teeth. This procedure is performed with local anesthesia.

Risks Related to the Suggested Treatment: While this could be considered a low risk procedure, risks related to gingivectomy/frenectomy surgery might include post-surgical infection, bleeding, bruising, swelling or pain. Risks related to the anesthetics include but are not limited to: allergic reactions, facial swelling, bruising, pain, soreness, or discoloration of the injection site.

No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed surgery will be completely successful in reducing the interference with the normal alignment of teeth or impingement on the gingival (gums). I may need to be retreated. It is anticipated that the surgery will provide benefit in reducing the cause of this condition.

Patient’s Endorsement:My signature on this form indicates that I have read and fully understand the terms within this document and the explanations referred to or implied, and that after thorough deliberation, I give my consent for the performance of the Gingivectomy/Frenectomy surgery as presented to me during the consultation by the Doctor and treatment coordinator.

I have read and understand the above.

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