COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or alcohol
intake may affect gum healing and may limit the successful outcome of my surgery. I agree to follow
instructions related to the daily care of my mouth and to the use of prescribed medications. I agree to
report for appointments as needed following my surgery so that healing may be monitored and the
doctor can evaluate and report on the success of the surgery.
SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, video recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures or publications,
provided my identity is not revealed.
PATIENT’S ENDORSEMENT: My endorsement (signature) to this form indicates that I have read and fully
understand the terms used within this document and the explanations referred to or implied. After
thorough consideration, I give my consent for the performance of any and all procedures related to tooth
extraction and the simultaneous use of bone grafting to attempt ridge augmentation as presented to me
during the consultation and treatment plan presentation by the doctor or as described in this document.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, AND CONSENT TO THE FOLLOWING TREATMENT: ________________________ ________________________________________________________________________