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INFORMED CONSENT FOR EXTRACTION
Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:
Registration Time:
INFORMED CONSENT FOR EXTRACTION
Tooth No:
I hereby provide my informed consent for the extraction of the specified tooth. I understand that there may be alternatives to tooth extraction; however, after the doctor's explanation, I have chosen to proceed with extraction. I acknowledge that despite all efforts to the contrary, there are certain normal complications that can occur as a result of the extraction(s), including but not limited to:
• Allergic reactions to medications or anesthetics used.
• Pain, swelling, infection, bruising, and bleeding.
• Stiffness of the nearby muscles.
• Numbness.
• Fracture of root tips, which may be left in place or displaced into the sinuses and/or nearby spaces.
• Occurrence of dry sockets, aspiration, and/or swallowing of foreign objects.
I understand that the dental care and treatment that will be performed have been thoroughly explained to me. I have had the opportunity to ask questions and seek clarification. I acknowledge that there is no warranty or guarantee as to any specific result and/or cure. I understand that the dentist has provided information on any known risks, benefits, and available alternatives, and I have considered them in making my decision to proceed with the extraction(s).
I am aware that this procedure can be performed by a specialist, but I have chosen to have it done in this office by a general dentist. I understand that the dentist will exercise their professional judgment throughout the procedure.
I understand that I have the right to refuse or withdraw consent at any time before the procedure.
I also have the right to seek a second opinion regarding my condition and treatment options. I acknowledge that any additional procedures or treatments beyond the extraction(s) will require separate informed consent.
By signing this consent form, I authorize the extraction, administration of anesthetics, and the taking of x-rays as necessary for the procedure. I understand that the dental clinic, its doctors, and staff will take reasonable measures to ensure my safety and well-being during the procedure. However, I acknowledge that complications and unforeseen events can occur.
I understand that I am responsible for the payment of all dental services provided to me, including but not limited to the tooth extraction procedure. I acknowledge that there is a strict no refund policy after the treatment is rendered. Any outstanding balances not covered by insurance or other forms of payment are my sole responsibility.
By signing below, I acknowledge that I have read and understood the above information and that all of my questions have been answered to my satisfaction, and I freely and voluntarily consent to undergo the recommended extraction(s) treatment, acknowledging the associated risks and potential complications, as well as the absence of guarantees or assurances regarding the outcomes. I understand and accept the financial responsibility for the extraction(s)treatment and any additional treatments required, and I release the dental clinic, its doctors, and staff from any liability arising from the treatment and its outcomes.
Patient Name:
Signature
Date
Witness Name
Signature
Date
Doctor name :
Dr.
Signature
Date
Patient Signature
Witness Signature
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