THPDental - Consent For Operation

Central Office

Personal Information 個人資料

Patient Name 病人姓名*

Date of Birth 出生日期*

Date of Operation 手術日期*

GENERAL RISKS ASSOCIATED WITH THE OPERATION
一般與手術有關的風險

The risks included 風險包括 :

Disturbance of inferior dental nerve / lingual nerve which may cause numbness to the corresponding Disturbance of inferior dental nerve / lingual nerve which may cause numbness to the corresponding area
影響下牙槽神經 / 舌頭神經 , 可能引致有關部位感覺麻痺

Postoperative wound pain , facial swelling and bruising
手術傷口及附近組織疼痛，面部紅腫及出現瘀血

Wound infection and bleeding
傷口感染

Others 其他

RELEVANT TREATMENT OPTIONS 其他治療方法

The doctor has explained other relevant treatment options and their associated outcomes and risks.
醫生已講解在療程中可能涉及的事項, 其他可供選擇的治療 (包括不進行治療) 的好處和風險, 及他們所關注的事項。

THE FOLLOWING LEAFLET HAS BEEN PROVIDED ( IF AVAILABLE ) 已提供予病人之資訊單張(如有)

Anaesthesia 麻醉須知

Dental Implant 口腔植齒

Wisdom Teeth 智慧齒

Others 其他

THE EXPLANATION GIVEN
有關的解釋

The doctor(s) have fully explained the above to the patient and / or the patient's parent or guardian. The doctor(s) have also indicated that they are welcome to discuss any further queries that they may have.
醫生已如上所述, 詳細向病人 / 病人的父母或監護人解釋, 並回答他們提出的問題。醫生並歡迎有關人士再提出任何問題。

CONSENT 同意

The doctor(s) have fully explained the above to me (the undersigned) which I fully understand. The doctor(s) also have answered the questions that I have asked.
I, the undersigned, consent to undergo / consent to the Patient undergoing the above operation under the appropriate anaesthesia determined by the doctor(s) . The doctor(s) has fully explained the nature , purpose , main risks and potential complications of the operation and the appropriate anaesthesia which I fully understand.

醫生已如上所述向我解釋, 並解答我提出的問題, 醫生亦歡迎我再提出任何問題, 我完全明白醫生的解釋和答案。
我 , 本同意書之簽署人 ,同意接受醫生建議的手術和適當的麻醉。醫生已向我詳細解釋此項手術的目的、主要風險、可能引起的併發症及所需麻醉的性質。我完全明白有關的解釋。

Name of Patient / Parent / Legal Guardian
病人 / 病人的父母或監護人姓名*

Patient’s / Parent’s / Guardian’s signature
病人 / 病人的父母或監護人簽署*

Name of Dentist 牙科醫生姓名*

Signature of Dentist 牙科醫生簽署*

Central Office

Consent For Operation病人接受牙科手術同意書

Consent For Operation
病人接受牙科手術同意書