Informed Consent For Tooth Removal printable pdf download

Informed Consent for Tooth Removal

I desire to have my (tooth or teeth) extracted. I have had alternative treatment and tooth replacement options (i.e. root

canal therapy, post/core and crown, bridge and implant procedures) explained to me. I also understand that my teeth

may shift after extraction, possibly causing mal-occlusion (damage to the way my teeth hit together). I have also been

made aware that treatment may result in infection, swelling, pain, and systemic disease.

I understand that there are risks associated with any dental and anesthetic procedure. These include, but are not limited

to:

Post-operative infection

Swelling, bruising, and pain

Damage to the adjacent teeth, fillings or crowns/bridges

Bleeding which may require further treatment

Anesthetic drug reactions and side effects including, nausea, dizziness, allergic reaction, prolonged

numbness, and needle breakage

Possibility of a small fragment of root or bone being left in the jaw when its removal is not appropriate. Such

fragments may work their way partially out of the tissue or need treatment at a later date

Damage to sinuses requiring additional treatment or surgical repair at a later date

Fracture or dislocation of the jaw

Damage to nerves resulting in temporary or possibly permanent numbness or tingling of the lip, chin, tongue,

or other areas.

I understand the recommended treatment, the fee(s) involved, the risks of treatment, and alternatives and risks of these

alternatives, including the consequences of doing nothing. I have had all of my questions answered and have not been

offered any guarantees.

Patient Signature ___________________________________________ Date________________________

Oral Care Following Surgery

On The Day of Surgery

Bite on gauze for at least 45 minutes to 1 hour with firm pressure. Change gauze as needed (every 30

minutes) with the sterile gauze given to you.

Take medication prescribed by the Doctor in the amount and at the times prescribed.

Place ice wrapped in a cloth on the cheek near area of surgery for 15 minutes, then remove for 15 minutes.

Repeat this process as much as possible. This will keep swelling to a minimum.

Avoid spitting or sucking motions (like sucking through a straw) and smoking for the first 12 hours, as this

will possibly dislodge the clot resulting in a painful healing period.

Eat. Proper nutrition promotes healing. However, stay with soft foods and avoid things like potato chips

which may easily get lodged in the extraction site(s).

Rinse with salt water 3 times a day (1 teaspoon of salt in one glass of water). Do this for at least 3 days.

Avoid mouthwashes like Listerine and Scope.

On The Day Following Surgery

Place a hot compress on the cheek near the site of surgery for 15 minutes, then remove for 15 minutes.

Repeat this process as much as possible. This will allow any swelling to go down.

Remember:

Moderate bleeding after surgery for the first few hours is normal. If bleeding persists after this period, repeat

placing gauze over surgery site, bite with firm pressure and call the Doctor.

Moderate swelling and pain are common, especially after surgical removal of impacted teeth. Use ice and the

pain medication prescribed to help keep the discomfort minimal.

Any questions will be answered by calling the office.

Informed Consent For Tooth Removal

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