13802 W Camino del Sol Suite #101
Sun City West, AZ 85375

(623) 583-0151


Please initial each paragraph after reading. If you have any questions, please ask your doctor before initialing.

I have been informed by Dr.

of my current condition and recommendation for treatment which includes (i.e., implant, sinus lift, cleft palate, orthogenetic, etc.)

I also understand that a separate procedure to obtain bone for grafting is intended to remove portions of bone from my (hip, leg, rib, jaw, skull, etc.) and place it in the area to be treated. In addition to the risks of the primary surgical procedure which have been explained to me separately, I understand that bone grafting itself involves specific risks. My doctor has explained to me that such risks include, but are not limited to, the following:


  1. Bleeding, swelling, infection, scarring, pain, numbness or altered sensation (possibly permanent) at the donor site which may require further treatment.
  2. Allergic or other adverse reaction to the drugs used during or after the procedure.
  3. The need for additional or more extensive procedures in order to obtain sufficient bone.
  4. Rejection of bone particles from donor or recipient sites for some time after surgery.
  5. Rejection of the bone graft.


  1. Damage to adjacent teeth which may require future root canal procedures, or may cause loss of those teeth.
  2. Removal of adult teeth in order to obtain sufficient bone material
  3. Numbness or pain in the area of the donor or recipient site, or more extensive areas, which may be temporary or permanent. Nerve damage can occur and the lip, chin, corner of the mouth, teeth, gums and other tissues in the area may feel numb, with loss of sensation and/or painful or tingling sensations that may last indefinitely. Though the risk is low, this must be included as a primary concern due to the lack of harvest and placement.
  4. Penetration of the sinus or nasal cavity in the upper jaw, which could result in infection or other complication requiring additional drug or surgical treatment. BANKED BONE (freeze-dried, lyophilized, demineralized, xenografts) OR BONE SUBSTITUTES, on occasion, additional donated, processed, or artificial bone substitutes are used to supplement the patient's bone, or to spare an extensive graft harvesting procedure. If used, such materials may have separate risks including, but not limited to:
  5. Rejection of the donated or artificial graft material.
  6. The remote chance of viral or bacterial disease transmission from processed bone.
  1. The purpose of the bone graft is too augment the bone deficiencies. An implant is required to have an adequate bone foundation to increase the success and prognosis.

Further, as we age, we all lose bone as part of this process and /or periodontal disease. As this occurs, bone can be lost that was added from this procedure, and future procedures are required to treat this deficiency. It comes as a separate procedure and cost.

  1. Additional bone may be required in adjunctive procedures based upon how your body adjusts to the graft and healing/resorbtion.


I acknowledge that the above has been explained to my satisfaction, my questions have been answered, and I understand the risks of bone grafting. I am fully aware that a perfect result cannot be guaranteed or warranted. My signature below indicates my understanding of my proposed treatment and I hereby give my willing consent to the surgery.

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