Informed Consent for Biopsy Purpose of Biopsy:

I understand that my dentist has recommended that I undergo a biopsy involving partial or complete removal of the lesion in the area of _. The purpose of the biopsy is to diagnose the lesion type. The diagnosis wil determine what follow-up care, if any, is required. Choosing not to proceed: I was informed that if I choose not to proceed with the biopsy, I risk the worsening of an undiagnosed problem which may impact my oral and general health. Consequences may include, but are not limited to, persistence and possible growth of the lesion.

Surgical Procedure may involve some, or all, of the following:

• Use of local anesthetic, oral or intravenous sedation, analgesics and sutures (stitches).
• Additional procedures during the biopsy which are not known to be needed at this time.
• Performance of diagnostic studies relating to my biopsy will be performed by other medical/dental professionals.

Risks and Complications of biopsy: 1 understand that the risks and complications include, but are not limited to:

• Need for additional surgery or referral to another specialist
• Stress or damage to jaw joints (TMJ)
• Scarring
• Exposure of root surfaces (recession)
• Allergic reactions to dental materials/medications
• Exposure of gaps between the teeth
• Bleeding
• Exposure of crown and bridge margins
• Swelling and/or infection
• Temporary restriction of mouth opening
• Pain and/or tooth sensitivity
• Increased tooth mobility
• Possible altered or loss of sensation due to dental nerve damage (teeth, gums, lips, tongue, cheeks, face, palate…)

Risks and Complications of local anesthetic use: I understand that the risks and complications associated with the use of local anesthetic include, but are not limited to: Nerve injury, which may occur from the delivery of local anesthesia, resulting in altered or loss of sensation,

numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions usually resolve, but in some cases may be permanent.

Consent to Unforeseen Conditions: During treatment, unknown conditions, such as discovery of changed prognosis for adjacent structures or teeth, may modify or change the original treatment plan. | therefore authorize the treating dentist to do additional or alternative procedures if, in his/her professional judgment, it is in my best interest.

Compliance with Self-Care Instructions: In order to increase the chance of achieving optimal results, | have provided an accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications, any allergies, recreational drug use, and pregnancy (if applicable).

I understand the necessity of maintaining good oral hygiene for better healing and that tobacco and alcohol products may negatively affect healing.

Supplemental Records and Their Use: | consent to photography, filming, 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 and words within this document and the explanations referred to or implied. After thorough deliberation, | give my consent for the performance of any and all procedures related to the completion of the biopsy as presented to me during the consultation and treatment plan presentation by the dentist.

You or your responsible party will have the opportunity to sign an electronic copy of this form when you arrive at our office for your appointment.

By signing the consent section of this patient consent form, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.