CONSENT OF ORAL SURGERY

The Doctor has explained to me the proposed treatment and the anticipated results of such treatment.

I understand that this is an elective procedure and that there are other forms of treatment available, including the option of no treatment.

The doctor has explained to me that there are certain potential risks in this treatment plan or procedure

This includes:

1. Injury to a nerve resulting in numbness or tingling of the chin, lip, cheek, gum and or tongue on the operated side, this can persist for several weeks.
2. Post operative infection requiring additional treatment.
3. Injury to adjacent teeth or fillings
4. Stretching of the corners of the mouth with resultant cracking and bruising
5. A small piece of root left in the jaw when removal would require extensive surgery

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post-treatment instructions have been explained to me.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.