Dental Extraction(S) Consent Form (Page 2 of 2) in pdf

Dental Extraction(S) Consent Form Page 2

9. Sharp ridges or bone splinters may form later at the edge of the socket. These may require another

surgery to smooth or remove them.

10. Incomplete removal of tooth fragments – to avoid injury to vital structures such as nerves or sinuses,

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 which may require additional care.

11. The upper back teeth can be very close to the sinus. In rare instances a communication between the

sinus and the extraction socket can occur. In extremely rare circumstances a toot or part of the tooth

can be pushed into the sinus. All these situations are full manageable.

12. Most procedures are routine and serious complications are not expected. Those, which do occur, are

most often minor and can be treated.

I hereby state that I have read and I fully understand this consent form. I have been given an

opportunity to ask any questions I might have had, that those questions have been answered in a

satisfactory manner.

Date ____________________________________________________

Time ____________________________________________________

Signature _______________________________________________

(Signature of relative or Representative)

Witness _________________________________________________

Dental Extraction(S) Consent Form Page 2