CONSENT FORM FOR SURGICAL TOOTH EXTRACTION


Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:

EXTRACTION is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache

Sometimes wisdom teeth are impacted (stuck and unable to grow normally into the mouth) and may cause recurrent infections of the gum (pericoronitis). Some extractions may require cutting into the gums and removing supporting bone and/or cutting the tooth into sections prior to removal. Extraction of teeth is an irreversible process and, whether routine or difficult, is a surgical procedure.

Teeth to be removed:

UpperRightThirdMolar

UpperLeftThirdMolar

LowerRightThirdMolar

LowerLeftThirdMolar

Other

I HAVE BEEN INFORMED and fully understand that there are certain inherent and potential risks associated with any type of surgical procedure. They include, but are not limited to the following:

  • Swelling and/or bruising and discomfort in the surgery area.
  • Stretching of the corners of the mouth resulting in cracking or bruising.
  • Dry socket - jaw pain beginning a few days after surgery, usually requiring additional care. It is more common from lower extractions, especially wisdom teeth.
  • Possible damage to adjacent teeth, especially those with large fillings or caps.
  • Numbness, pain, or altered sensations in the teeth, gums, lip, tongue (including possible loss of taste sensation), and chin, due to the closeness of tooth roots (especially wisdom teeth) to the nerves, which can be bruised or damaged. Almost all sensation returns to normal, but in rare cases, the loss may be permanent.
  • Trismus - limited jaw opening due to inflammation or swelling, most common after wisdom tooth removal. Sometimes it is the result of jaw joint discomfort (TMJ), especially when TMJ disease already exists.
  • Bleeding - significant bleeding is not common, but persistent oozing can be expected for several hours.
  • Sharp ridges or bone splinters may form later at the edge of the socket. These usually require another surgery to smooth or remove.
  • Incomplete removal of tooth fragments - to avoid injury to vital structures such as nerves or sinus, sometimes small root tips may be left in place.
  • Sinus involvement - the roots of upper back teeth are often close to the sinus, and sometimes a piece of root can be displaced into the sinus or an opening may occur into the mouth that may require additional care.
  • Jaw fracture - while quite rare, it is possible in difficult or deeply impacted teeth.

I UNDERSTAND that it is possible for an infection to occur in the extraction site and that I may need antibiotics and/or other procedures to treat the infection.

I UNDERSTAND the nature and purpose of the proposed procedure(s)/treatment(s)/invasive diagnostic(s), the prognosis of my medical condition with and without the proposed intervention, the risks and possible discomforts involved, the benefits of the procedure(s)/treatment(s)/invasive diagnostic(s), other effective alternatives of procedure(s)/treatment(s)/invasive diagnostic(s) (if any), and the possibilities of complications. That the possibility and nature of complications cannot always be accurately anticipated and, therefore, there is and can be no guarantee, either expressed or implied, as to the results of the proposed treatment(s)/procedure(s)/invasive diagnostic(s).

I HAVE PROVIDED complete and accurate medical and personal history, including current medication prescription and non-prescription, which I take, and any known drug allergies.

I WILL FOLLOW all instructions as explained and directed to me, and will permit recommended diagnostic procedures, including x-rays.

I UNDERSTAND that the practice of dentistry is not an exact science and know that guarantees have not been made to me concerning the results of the procedure.

I WAS ABLE to ask questions to the doctor about my condition and the risks of the procedure(s)/treatment(s)/invasive diagnostic(s). I have given the possible risks and complications which may happen to this procedure.

I HAVE BEEN given an opportunity to read this form and my questions have been discussed and answered to my satisfaction. I fully understand possible risks, complications, and benefits that can result from the procedure(s)/treatment(s)/invasive diagnostic(s).

I HAVE BEEN given enough information to give this informed consent. By signing this Consent Form, I understand that I have not waived any of my legal rights.


Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date