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          This document reflects my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable as a corollary to the planned endodontic surgery

performed by Dr. Alexander Kutuza and his surgical assistant(s). 

I agree to the use of local anesthesia, depending upon Dr. Kutuza's judgment.

         I am aware that complications of microsurgery and anesthesia may include the following: pain, swelling, trismus (restricted jaw opening), infection, bleeding, sinus involvement, numbness or tingling of the lip, gum or tongue,

which rarely are protracted, and even more rarely, are permanent.

I understand that it is my responsibility to report any symptoms to Dr. Kutuza immediately.

          Occasionally, medication will be prescribed by your endodontist.  Medications prescribed for discomfort and/or sedation may cause drowsiness, which can be increased by the use of alcohol or other drugs.  We advise that you do not operate a motor vehicle or any hazardous device while taking such medications.  In addition, certain medications may cause allergic reactions, such as hives or intestinal discomfort. 

If any of these problems occur, call Dr. Kutuza immediately. 

It is the patient's responsibility to report any changes in his/her medical history to Dr. Kutuza.

           It has been explained to me, and I understand, that a perfect result from surgery is not guaranteed.  I have been given the opportunity to question Dr. Kutuza concerning the nature of the treatment,

the inherent risks of the procedure(s), and the alternative(s) to such treatment(s).  

This consent form does not encompass the entire discussion

I had with Dr. Kutuza regarding his/her proposed treatment(s).

           I hereby authorize Dr. Alexander Kutuza and his surgical assistant(s)

to provide treatment for the condition(s) described. 

           Furthermore, I give Dr. Alexander Kutuza my permission to record, videotape and/or take photos of my procedure.  These photographs may be used for purposes of documentation, education and/or teaching.



SIGNATURE__________________________________ NAME_______________________________________DATE_____________________________________________

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