Dental Extraction(S) Consent Form

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Consent for Extraction of Teeth
ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION
State law requires that you be given certain information and that we obtain your consent prior to
beginning any surgical dental treatment. What you are being asked to sign is a confirmation that we
have discussed the nature and purpose of the treatment, the known risks associated with the treatment,
and the feasible treatment alternatives; that you have been given an opportunity to ask questions; that
all your questions have been answered in a satisfactory manner. Please read this form carefully before
signing it and ask about anything that you do not understand. We will be pleased to explain.
CONSENT FOR Tooth Extraction
I hereby authorize and direct Dr. ______________________ to perform surgical tooth extraction (or
upon any person identified above as the patient, for whom I am empowered to consent)
Tooth #___________________________________________________________.
Location(s)__________________________________________________________.
I understand that it may be necessary to place sterilized human bone matrix to help augment the
extraction socket for future dental implants, bridges or dentures. Extraction of teeth is an irreversible
process and whether routine or difficult is a surgical procedure. We will do everything we can to make
sure your treatement is problem free. As in any surgery, there are some risks.
These risks include, but are not limited to:
1. Swelling and or bruising and discomfort in the surgery area.
2. Stretching of the corners of the mouth resulting in cracking and bruising.
3. Possible infection requiring further treatment.
4. Dry socket – jaw pain beginning a few days after surgery, usually requiring additional care, it is more
common from lower extractions, especially wisdom teeth.
5. Possible damage to adjacent teeth, especially those with large fillings or caps.
6. The lower back teeth are adjacent to a large nerve. Numbness or altered sedation in the teeth, lip,
tongue and chin, due to the closeness of tooth roots (especially wisdom teeth) to the nerves which can
be bruised or injured. Sensation most often returns to normal, but in rare cases, the loss may be
permanent.
7. 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 and
symptoms already exist.
8. Bleeding – significant bleeding is not common, but persistent oozing can be expected for several
hours.

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