Bisphosphonate Waiver Please complete this Bisphosphonate Waiver. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header, DOB as dropdowns and no captcha (change), 2020-06-04Patient name:(* required) First Last Patient date of birth:(* required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Bisphosphonate WaiverHaving been treated previously with oral bisphosphonate drugs (sometimes used in cancer treatment or for osteoporosis, you should know that there is a very small but real risk of future complications associated with dental treatment. This risk is currently estimated to be less than 2/10 of 1 percent up to 4 percent. Bisphosphonate drugs appear to adversely affect the health of jaw bones, thereby reducing or eliminating the jaw bone’s ordinarily excellent healing capacity. This risk is increased after surgery, especially with extraction, implant placement or other “invasive” procedures that might cause even mild trauma to the bone. Spontaneous exposure of the jawbone (osteonecrosis) can result. This is a smoldering, long-term, extremely painful and destructive process in the jaw bone that is often very difficult or impossible to eliminate. Your medical/dental history is very important. We must know the medications and drugs that you have received or taken or are currently receiving or taking. An accurate medical history, including names of physicians, is important for us to access your risk. The decision to discontinue oral bisphosphonate drug therapy before dental treatment should be made by you in consultation with your medical doctor. 1. If a complication occurs, antibiotic therapy may be used to help control infection. For some patients, such therapy may cause allergic responses or have undesirable side effects such as gastric discomfort, diarrhea, colitis, etc.(* required) I confirm! 2. Despite all precautions, there may be delayed healing, osteonecrosis, loss of bone and soft tissues, pathologic fracture of the jaw, oral cutaneous fistula (open draining wound), or other significant complications.(* required) I confirm! 3. If osteonecrosis should occur, treatment may be prolonged and difficult, involving ongoing intensive therapy, including hospitalization, long-term antibiotics and surgical debridement to remove nonvital bone. Reconstructive surgery may be required, including bone grafting, metal plates and screws, and/or skin flaps and grafts.(* required) I confirm! 4. Even if there are no immediate complications from the proposed dental treatment, the area is always subject to spontaneous breakdown and infection because of the condition of the bone. Even minimal trauma from a toothbrush, chewing hard food or denture sores may trigger a complication.(* required) I confirm! 5. Long-term post-operative monitoring may be required, and cooperation in keeping scheduled appointments is important. Regular and frequent dental check-ups with your dentist are important to monitor and attempt to prevent breakdown in your oral health.(* required) I confirm! 6. I have read the above paragraphs and understand the possible risks of undergoing my planned treatment. I understand and agree to the following treatment plan.(* required) I confirm! 7. I understand the importance of my health history and affirm that I have given any and all information that may impact my care. I understand that failure to give true health information may adversely affect my care and lead to unwanted complications.(* required) I confirm! 8. I realize that, despite all precautions taken to avoid complications, there can be no guarantee as to the result of the proposed treatment.(* required) I confirm! SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Waiver?(* required) Yes No E-mail address:(* required) CONSENT: I certify that I speak, read and write English (or had help from a translator) and have read and fully understand this consent for surgery, have had my questions answered, and that all blanks were filled in prior to my initials or signature. Please sign:(* required) Reset signature Signature locked. Reset to sign again Important: You consent to sign this document electronically.