DIAGNOSIS: I have been informed of the presence of a frenum that might be exceptionally short, thick,
tight, or may extend too far down along the gum. When a frenum is positioned in such a way as to
interfere with the normal alignment of teeth or to impinge on the gingiva (gums), it can be excised with
a surgery called a Frenectomy.
PURPOSE OF FRENECTOMY SURGERY: A Frenectomy is a simple surgical procedure that removes or
loosens a band of tissue that is connected to the lip, cheek or floor of the mouth. The surgery can cause
very little bleeding, does require sutures, and often results in some post-procedure discomfort. Other
complications can include trauma to the nerve tissue or blood vessels that may lead to loss of sensation
of lip tongue check or other tissues in the mouth or altered sensation or pain. The procedure will be
performed using a local anesthetic.
RISKS RELATED TO THE SUGGESTED TREATMENT: While this could be considered a
low risk procedure, risks related Frenectomy surgery might include but are not limited to postsurgical
infection, bleeding, brushing, swelling, or pain. There is always a chance of trauma
to the nerve tissue or blood vessels that may lead to loss of sensation of lip tongue check or other tissues
in the mouth or altered sensation or pain. Risks related to the anesthetics might include but are not
limited to allergic reactions, accidental swallowing of foreign matter, facial swelling or bruising, pain,
soreness or discoloration at the site of injection of the anesthesia.
NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty or assurance has
been given to me that the proposed surgery will be completely successful in reducing the interference
with the normal alignment of the teeth or impingement on the gingiva (gums). It may need to be
retreated. It is anticipated (hoped) that the surgery will provide benefit in reducing the cause of this
SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, filming, recording and x-rays of my
oral structures as related to these procedures.
CONSENT TO UNFORESEEN CONDITIONS: During surgery, unforeseen conditions may be discovered
which call for a modification or change from the anticipated surgical plan. I therefore consent to the
performance of such additional or alternative procedures as may be deemed necessary in the best
judgment of the treating doctor.
COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or
alcohol intake may affect gum healing and may limit the successful outcome of my surgery. I agree to
follow instructions related to my own daily care of my mouth. I agree to report for appointments following
my surgery as suggested so that my healing may be monitored and so that the doctor can evaluate and
report on the outcome of surgery upon completion of healing.
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,
and that after thorough deliberation, I give my consent for the performance of any and all procedures
related to Frenectomy surgery as presented to me during consultation and treatment plan presentation
by the doctor or as described in this document.
I have read and fully understood the terms within this document and consent to the procedure as
I have read and fully understood the terms within this document and refuse to give my consent for the
proposed treatment plan as described above. I have also been informed of and accept the consequences
if no treatment is administered.
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and submitting this document, we are assuming that it has been read in its entirety.
All patient signatures will be verified for authenticity in the office.