Biopsy with Local Anesthesia Consent

Informed Consent for Biopsy with Local Anesthesia

Patient Name:

My dentist has recommended that I undergo a biopsy of a lesion, which is a procedure in which a portion of the lesion or, all of the lesion will be removed. The expected result of this procedure is to adequately diagnose the lesion type.

I understand that there are risks and complications associated with this procedure, which include, but are not limited to: infection, need for another biopsy to be performed, and scarring. In extreme cases, swelling, bruising and/or numbness of the face and tongue can occur. This can also be permanent.

Understanding all of the above, I request that and hereby provide my informed consent to the treating doctor and his/her assistants to perform a biopsy. I understand that in the course of the biopsy it may become necessary to perform additional procedures, which, are not known to be needed at this time. I request that and hereby provide my consent to the doctor to perform such procedure at his/her discretion if needed during my biopsy.

I consent to having local anesthesia. I understand that, the performance of diagnostic studies, relating to my biopsy, will be performed by other medical/dental professionals.

I confirm with my signature that:

• My dentist has discussed the above information with me.

• I have had a chance to ask questions.

• All of my questions have been answered to my satisfaction.

• I do hereby consent to the treatment described in this form.

Signature of Patient (or parent or legal guaridan):

Relationship to Patient:

Date:

Press the button below to submit the completed consent form.