General Oral Surgery Procedures

NorthStar Implant Dentistry, P.C. | Informed Consent for Oral Surgery | Rev. 09/2026 Page 1 of 4 © 2026 NorthStar Implant Dentistry, P.C. All rights reserved. Confidential and proprietary intellectual property; reproduction, distribution or use outside the practice requires express written permission. NORTHSTAR IMPLANT DENTISTRY, P.C. Briarwood • Manhattan • Commack | northstarimplants.com INFORMED CONSENT FOR ORAL SURGERY Universal surgical & anesthesia consent This form is a record of the conversation you had with your surgeon — it is not a substitute for it. Read it, or ask us to read it to you. Circle or underline anything you want explained again. Do not sign until every question you have has been answered. You may change your mind and stop at any point before the procedure begins. Patient name Date of birth Chart / MRN Today's date Time Treating surgeon 1. MY CONDITION AND THE TREATMENT I AM AGREEING TO Diagnosis / reason for treatment Planned procedure(s), teeth and sites Check every procedure planned for this visit: Simple tooth extraction Surgical / impacted extraction Wisdom tooth removal Coronectomy Retained root removal Dental implant placement Implant uncovering / abutment Bone graft / ridge preservation Sinus lift (internal or lateral) Autogenous bone harvest Guided tissue membrane Biologics / growth factors (PRF, PRP, BMP) Venipuncture / IV access Marrow aspiration Connective tissue graft Acellular dermal graft Frenectomy Apicoectomy / root-end surgery Incisional biopsy Excisional biopsy Incision and drainage Alveoloplasty / alveolectomy Vestibuloplasty Removal of hardware / failed implant Other procedure(s) Alternatives we discussed — including the option of no treatment at all, and what is likely to happen with each: No treatment / watch and wait Delay treatment Non-surgical care (medication, root canal, periodontal therapy) Removable denture or partial Fixed bridge Referral or second opinion Alternatives, in my surgeon's words Restorative dentist for the crown / bridge / denture, if any Est. visits / healing time 2. RISKS THAT APPLY TO ANY ORAL SURGERY No surgery is risk-free, and no result can be promised or guaranteed. The risks below are the ones a reasonable patient would want to know about. They are grouped by how often they happen. This list cannot include every possible complication. • Common, and usually temporary: pain; swelling; bruising; bleeding and oozing for the first day; stiff jaw and limited mouth opening; sore throat; cracked or sore corners of the mouth; bad taste or odor; nearby teeth feeling loose or sensitive; a small amount of numbness for a few hours after local anesthetic. • Less common: infection needing antibiotics, drainage, or a second procedure; dry socket; slow or incomplete healing; damage to nearby teeth, fillings, crowns, bridges, dentures or braces; cuts, burns or bruises of the lip, cheek, gum or tongue; jaw joint (TMJ) pain, clicking or locking; scarring; small pieces of tooth or bone that work their way out later or must be removed; allergic or other adverse reaction to a medicine or material; a change in how the teeth fit together. • Uncommon, but serious: nerve injury — numbness, tingling, burning, or pain in the lip, chin, cheek, gums, teeth or tongue, and/or a change or loss of taste. This can come from the surgery itself or from the anesthetic injection. It usually improves over weeks to months, but it can last longer and in some cases is permanent; an opening between the mouth and the sinus or nose that may need a second operation to close; a tooth, root or implant pushed into the sinus or another space; broken jaw; infection that spreads into the face or neck and requires hospital care; bleeding heavy enough to need a transfusion; swallowing or breathing in a small instrument or fragment. • Rare: medication-related osteonecrosis of the jaw (MRONJ) — bone that will not heal and stays exposed. The risk is higher if you take or have ever taken bone-strengthening or anti-cancer drugs such as alendronate (Fosamax), zoledronic acid (Reclast, Zometa), denosumab (Prolia, Xgeva), or certain targeted therapies, or if you have had radiation to the jaws; permanent change in facial appearance; life-threatening complications. Things that make your risk higher. Smoking or vaping, alcohol or recreational drug use, uncontrolled diabetes, steroids or drugs that lower immunity, blood thinners, previous radiation to the head or neck, and poor oral hygiene all significantly increase the chance of infection, dry socket, poor healing, and failure of grafts and implants. Tell your surgeon now if any of these apply to you.

NorthStar Implant Dentistry, P.C. | Informed Consent for Oral Surgery | Rev. 09/2026 Page 2 of 4 © 2026 NorthStar Implant Dentistry, P.C. All rights reserved. Confidential and proprietary intellectual property; reproduction, distribution or use outside the practice requires express written permission. INFORMED CONSENT FOR ORAL SURGERY Patient: ______________________________ 3. ADDITIONAL RISKS — these apply only to the procedures checked in Section 1 • Wisdom teeth, lower molars and coronectomy. These teeth sit closest to the nerve that supplies the lower lip, chin and tongue, so the chance of numbness is higher than for other teeth. Upper teeth sit against the sinus. In a coronectomy the root is left in place on purpose; it may later become infected, move toward the surface, or need to be removed in a second procedure. • Dental implants. The implant may fail to fuse with the bone, loosen, break, or have to be removed — sometimes months or years later. Bone and gum can be lost around an implant (peri-implantitis). Your anatomy may make it impossible to place the implant as planned, in the ideal position, or at all, and the plan may change during surgery. You may see gum recession, metal showing through the gum, an uneven gum line, or a result you do not find attractive. Screws and crowns can loosen or fracture and need repair or replacement. Implants are not permanent, are not guaranteed for life, and need cleaning and regular check-ups just like teeth. The crown, bridge or denture that attaches to the implant is separate treatment with a separate fee, and is often done by another dentist. • Bone grafts, membranes and sinus lifts. The graft may become infected, come apart, be partly or completely lost, or not produce enough bone — in which case grafting may have to be repeated or the plan abandoned. A membrane may become exposed and need removal. In a sinus lift, the sinus membrane can tear, and you may get sinus congestion, a sinus infection, or graft material moving into the sinus. Grafted bone can shrink over time. • Graft material. Donor and animal-derived grafts are processed, screened and regulated; the chance of passing on an infection is extremely small but is not zero. Tell us now if you decline donor or animal tissue for personal or religious reasons. • Soft tissue grafts (connective tissue, acellular dermal). Pain and bleeding at the donor site on the palate; graft shrinkage or loss; color or texture that does not match the surrounding gum; incomplete coverage requiring a repeat graft. • Biopsy. The tissue removed is sent to a pathology laboratory. A biopsy identifies a lesion but does not by itself treat it, and further surgery or referral may be needed. Results usually take one to two weeks; we will contact you, and you should call us if you have not heard back. • Apicoectomy. Root-end surgery may not save the tooth, and the tooth may still need to be removed later. • Frenectomy. The band of tissue can re-form or scar down, and a second procedure is sometimes needed. Speech, feeding or orthodontic results vary and are not guaranteed. • Alveoloplasty, alveolectomy, vestibuloplasty. Reshaping the ridge changes its height and shape, so a denture made before surgery will usually need relining or remaking, at additional cost. • Venipuncture and marrow aspiration. Bruising, pain, swelling, infection, or irritation of a nerve or vein at the site; rarely a blood clot in the vein or lasting discomfort. • Incision and drainage. You may need repeat drainage, a drain left in place for several days, IV antibiotics, or admission to a hospital. If grafting: material to be used Donor site, if your own bone Graft will be placed at Your own bone (autogenous) Human donor (allograft) Bovine / porcine (xenograft) Synthetic (alloplast) Biologic / growth factor Membrane (resorbable / titanium) 4. ANESTHESIA AND SEDATION Type I have chosen, after discussing the options: Local anesthesia only Nitrous oxide (laughing gas) Oral / minimal sedation IV moderate sedation Deep sedation or general anesthesia Anesthesia provided by NYS certificate / license # • All anesthesia, including local: allergic or adverse reaction to a drug; pain, swelling, bruising or lasting numbness where an injection or IV is placed; nerve injury from an injection; nausea and vomiting; dizziness, confusion, poor coordination or grogginess that can last into the next day; being aware of parts of the procedure. • Sedation and general anesthesia also carry: trouble with breathing or the airway; low blood pressure or an irregular heartbeat; stomach contents entering the lungs; sore throat, hoarseness, or injury to teeth, lips or gums if a breathing tube or airway device is used; and — rarely — heart attack, stroke, brain injury, or death. If you are having any sedation or general anesthesia, initial each line: I have had nothing to eat or drink for at least 6 hours (clear liquids only up to the time I was told). I understand that eating or drinking before sedation can be life-threatening. I have told this office about every medicine and supplement I take, including blood thinners, bone-strengthening drugs, steroids, herbal products, and any GLP-1 medicine such as semaglutide (Ozempic, Wegovy), tirzepatide (Mounjaro, Zepbound) or liraglutide — these can keep food in the stomach and change the fasting instructions I need. I took my usual prescribed medicines exactly as instructed, with small sips of water. A responsible adult is with me today, will drive me home, and will stay with me until I have recovered. For 24 hours I will not drive, operate machinery or power tools, drink alcohol, be the only adult caring for a child, or sign legal or financial documents. I understand the medicines may not fully wear off for a day.

NorthStar Implant Dentistry, P.C. | Informed Consent for Oral Surgery | Rev. 09/2026 Page 3 of 4 © 2026 NorthStar Implant Dentistry, P.C. All rights reserved. Confidential and proprietary intellectual property; reproduction, distribution or use outside the practice requires express written permission. INFORMED CONSENT FOR ORAL SURGERY Patient: ______________________________ I am not pregnant, or I have told the office that I may be pregnant or am breastfeeding. 5. MEDICINES AND PAIN CONTROL Most oral surgery pain is controlled best by alternating ibuprofen and acetaminophen on a schedule, not by opioids. If an opioid is prescribed for you, we have discussed the following: • It is for short-term use only. New York limits an initial opioid prescription for acute pain to a 7-day supply. • Opioids cause drowsiness, constipation, nausea and slowed breathing, and can lead to dependence, addiction and overdose — the danger is much higher when combined with alcohol, benzodiazepines, muscle relaxants, sleep aids or other sedatives. • Do not drive or work while taking them. • Keep them locked away from children, teenagers, visitors and pets, and take what you do not use to a drug take-back site. Never share them. • Naloxone (Narcan) reverses an overdose, is available without a prescription, and may be recommended for your home. • Antibiotics can cause upset stomach, diarrhea, C. difficile infection, yeast infection, rash or a serious allergic reaction, and may make hormonal birth control less reliable. Opioid risks discussed No opioid planned Patient declines opioids History of substance use disorder disclosed 6. MY PART IN THE RESULT • I have given a complete and accurate medical and dental history, including all conditions, all prescription and non-prescription medicines and supplements, allergies, recreational drug use, and pregnancy. I will tell this office right away if anything changes before my surgery. • I have been told that smoking, vaping and alcohol significantly increase the risk that my extraction site, graft or implant will fail, and I have been advised to stop. • I will follow the written and spoken instructions I am given before and after surgery, take medicines as prescribed, keep my mouth clean, keep my appointments, complete the treatment plan, and call the office promptly if a problem comes up. • I understand that if I do not do these things, I am more likely to have a complication or a poor result, and that additional treatment to correct it may be at my own expense. 7. WHAT I UNDERSTAND AND AGREE TO • Dentistry and surgery are not exact sciences. No one has promised or guaranteed me a particular result, how long treatment will take, or how long the result will last. • Once surgery has begun, my surgeon may find conditions that were not visible on the examination, x-rays or scan. I authorize my surgeon to change, extend, or stop the procedure if, in their professional judgment, that is medically reasonable and in my best interest — including while I am sedated and cannot be asked. • I may need more visits, more tests, referral to another specialist, further surgery, or hospital care. • Surgical fees are separate from fees for anesthesia and from fees for crowns, bridges or dentures, and additional or corrective treatment may cost more. Insurance may not cover all of it. • Photographs, x-rays, scans, models and records made in the course of my care are part of my dental record and are kept by the practice; I may request copies. • I may withdraw this consent and stop treatment at any time before the procedure begins. 8. PHOTOGRAPHS, IMAGES AND RECORDS — optional; initial only what you agree to Photographs, video, x-rays and scans may be taken and used for my own diagnosis, treatment planning and dental record. (Required in order to provide care.) They may also be used without my name for teaching, professional lectures, study clubs and publication in professional literature. They may also be used without my name on the practice website, in advertising and on social media. I understand that once an image is published online it may be copied and may not be possible to withdraw completely. I may revoke this in writing for future use at any time. I do NOT consent to marketing or social media use 9. LANGUAGE, QUESTIONS AND UNDERSTANDING Preferred language Interpreter name / ID / service Discussion held in English Professional interpreter used Telephone / video interpreter Adult family member interpreted at my request Written materials provided

NorthStar Implant Dentistry, P.C. | Informed Consent for Oral Surgery | Rev. 09/2026 Page 4 of 4 © 2026 NorthStar Implant Dentistry, P.C. All rights reserved. Confidential and proprietary intellectual property; reproduction, distribution or use outside the practice requires express written permission. INFORMED CONSENT FOR ORAL SURGERY Patient: ______________________________ I have read this form, or it has been read to me in a language I understand. I had enough time to read it and to ask questions. My questions were answered in a way I understand. I was able to describe, in my own words, what is going to be done and what the main risks are. I am signing this freely, and I am not under the influence of alcohol, drugs or sedative medication at the time I sign. I have been offered a copy of this signed form. SIGNATURES Signature of patient or legal representative Date Time Print name If not the patient: relationship and legal authority (parent, guardian, health care proxy, power of attorney) Interpreter signature (if used) Date Witness signature (optional) Date CLINICIAN ATTESTATION I personally discussed with this patient, or the patient's legal representative, the diagnosis; the nature and purpose of the proposed procedure; its reasonably foreseeable risks and benefits; the reasonable alternatives, including no treatment, and their risks and benefits; and the anesthesia plan — in plain language, and through an interpreter where one was needed. I asked the patient to tell me in their own words what is planned and what the main risks are, and I am satisfied that they understood. I answered all questions. In my judgment the patient or representative has the capacity to decide and is consenting voluntarily. This discussion has been documented in the patient's record. Surgeon signature Print name NYS license # Date / time Additional clinician or assistant present (optional) Print name and role Date ADDITIONAL DISCUSSION AND QUESTIONS ASKED — optional; part of the record Anything discussed that is not covered above — the patient's specific questions and the answers given, material risks specific to this patient, findings reviewed, or a plan the patient declined: OFFICE USE Signed original scanned to chart Copy offered / given to patient Pre- and post-op instructions given Medical history reviewed and updated today Medical clearance on file Antibiotic prophylaxis indicated Anticoagulant protocol reviewed PMP (I-STOP) checked, if prescribing Consent obtained by Date / time Procedure date Retention: scan the signed original into the patient record before the procedure begins, and offer the patient a copy. Re-confirm and re-date this consent if the treatment plan changes materially, if the anesthesia plan changes, or if more than 90 days pass before the procedure is performed.