Stateline Oral & Maxillofacial Surgery, PC


Note to patients:  this is a synopsis of the consent form used in our office.  The actual form may differ in small details from this text.  The doctor will review the risks and benefits associated with this surgery before you are given the opportunity to sign the actual consent form.


You have the right to be given pertinent information about your proposed surgery so that you may make an informed decision as to whether or not to proceed.  A biopsy is a surgical procedure whereby a sample of tissue is taken for microscopic study to determine if it is normal.


It is planned to:

o   Remove the suspected tissue totally.  If the biopsy report is suspicious, it may be necessary to return to the area to remove additional tissues to obtain a margin of safety,


o   Remove only enough tissue to get a good sample, leaving the remaining tissue behind. (This is usually done when the lesion is large, it is suspected to be benign, or the removal of all of it at this time would be unnecessarily difficult.)  However, if the biopsy report is suspicious, the entire lesion may have to be removed later.  

I understand that a biopsy requires an incision(s) in my mouth or on the skin which will require stitches, and sometimes the removal of bone tissue.  It has been explained that there are certain risks associated with the surgery, including (but not limited to):

A.     Post-operative discomfort and swelling that may require several days of at-home recuperation.

B.      Prolonged or heavy bleeding that may require additional treatment.

C.     Post-operative infection that may require additional treatment.

D.     Stretching of the corners of the mouth that may cause cracking and bruising and which may heal slowly.

E.      Restricted mouth opening for several days. Sometimes related to swelling and muscle soreness and sometimes related to stress on the jaw joints (TMJ).

F.      Reactions to medications, anesthetics, sutures, etc.

G.     Injury to sensory nerve branches in the area of the biopsy which may result in pain or a tingling or numb feeling in the lip, chin, tongue, cheek, gums or teeth, or in areas of the skin of the face.  Usually this disappears slowly over several weeks or months, but occasionally the effects may be permanent.

H.     If bone tissue is removed, healing may take longer, some complications may be more likely (for example, bleeding), and the biopsy report may take longer due to special processing requirements.

I.       Opening into the sinus (a normal bony chamber above the upper back teeth) requiring additional treatment.

J.       There is always a possibility of the lesion recurring in the same area, even when it appears to be totally removed.

                           It has been explained to me that during the course of surgery unforeseen conditions may be revealed which may necessitate extension of the original procedure or a different procedure from that planned.  I authorize my doctor to perform such additional procedures as are necessary in the exercise of professional judgment.



The anesthetic I have chosen for my surgery is:

1      Local Anesthesia

2      Local Anesthesia with Nitrous Oxide/Oxygen Sedation

3     Local Anesthesia with Oral Sedation

4      Local Anesthesia with Intravenous Sedation / General Anesthesia



         Anesthetic risks include: discomfort, swelling, bruising, infection, and allergic reactions.  There may be inflammation at the site of an intravenous injection (phlebitis) which may cause prolonged discomfort and/or disability and may require special care.  Nausea and vomiting, although rare, may be unfortunate side effects of IV anesthesia.  Intravenous anesthesia is a serious medical procedure and, although considered safe, carries with it the risk of heart irregularities, heart attack, stroke, brain damage or death.



            I understand that I may be given appointments for long-term follow-up care after my biopsy, even if the biopsy report is benign.  Follow-up care may be arranged with your general dentist or with this office.  I recognize the importance of returning for such follow-up that, if not done, may allow progression of my condition to a state requiring additional care or further surgery, or the lesion may recur and become a threat to my health.  I agree to comply by regularly scheduling exams as instructed and to notify this office if I suspect a change in my condition.


         Please be advised that any pathology report that is generated as a result of this biopsy may be sent to the referring doctors of record and to your insurance companies.  Please refer to the Notice of Privacy Practices and to the Consent for the use of Private Health Information as published by this office for detailed information.


I understand that no guarantee can be promised and I give my free and voluntary consent for treatment.  My signature below signifies that all questions have been answered to my satisfaction regarding this consent and I fully understand the risks involved in the proposed surgery and anesthesia.  I certify that I speak, read and write English.