The procedure necessary to treat the condition has been explained to me as socket and ridge preservations with bone grafting. I have been informed that following extraction of a tooth, the loss of jaw bone height and width may result in 40%-60% loss of bone height and width within 2-3 years or sooner. I have been informed that it is important to maintain volume of bone for future implant placement of partial or full removable denture.

The material of choice for the bone grafting is xenograft (bovine based).

I understand that there are other forms of treatment or no treatment at all are choices. I have been in informed of the risks of those choices that have been presented to me.

The common associated risks and side effects associated with my proposed bone grafting treatment and in this specific instance, they include but are not limited to:

  • Post operative discomfort and swelling
  • Bleeding that may require additional treatment
  • Post operative infection that may adversely affect the new bone graft and require additional treatment.
  • Failure of the graft to integrate with natural bone
  • I understand that smoking, excess alcohol, or sugar may affect gum healing and may limit the success of the procedure. I agree to follow my doctors home care instruction. I agree to report to my doctor for regular examinations as recommended. It is important to take any regular medications (high blood pressure, antibiotics, etc.) or any medications provided by your dentist, using only a small sip of water. It has been explained that during the course of treatment unforeseen conditions may be revealed that require changes in the procedure noted in paragraph 2 above. I authorize my doctor and staff to use professional judgement to perform such additional procedures that are necessary and desirable to complete my surgery. Following my discussions with the dentist, I have chosen to have bone grafting material placed in my extracted tooth bone socket. It has been explained to me and I understand that results cannot be guaranteed.

If you have any questions, please ask a member of our team.

Please sign (electronically) and date at the bottom of the form to authorize treatment

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Dr Olga Argyros

Practice Principal

Dr Sharon Stern

Specialist Endodontist

Dr Bryar Koyi

Specialist Periodontist and Implantologist

Dr Deborah Lipman

Associate Dentist

Mrs Emma Windust

Dental Nurse

Mrs Karen Brown

Dental Nurse

Mrs Runak Nasir

Trainee Dental Nurse

Miss Luciana Visintin

Dental Hygienist

Mrs Lisa Statham


Mrs Lydia Wedderburn

Practice Manager

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