Tooth Extraction Informed Consent printable pdf download

TOOTH EXTRACTION INFORMED CONSENT

Patient’s Name: ________________________________________________ Date of Birth: ________________________

This form and your discussion with your doctor are intended to help you make informed decisions about your surgery. As a member of the treatment

team, you have been informed of your diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the procedure, and any

associated costs. You should consider all of the above, including the option of declining treatment, before deciding whether to proceed with the

planned procedure. Your doctor will be happy to answer any questions you may have and provide additional information before you decide whether

to sign this document and proceed with the procedure.

Diagnosis: _______________________________________________________________________

Alternative treatment options: No Treatment

Procedure: _____________________________________________________________________________________________________________

I have been informed of and understand the potential risks related to this surgical procedure include but are not limited to:

Pain, swelling, bleeding, infection, bruising, delayed healing, scarring, damage to other teeth and/or roots that may result in the need for tooth

•

repair or loss, loose tooth/teeth, damage to dental appliances, cracking and/or stretching of the corners of the mouth, cuts inside the mouth or

on the lips, jaw fracture, stress or damage to the jaw joints (TMJ), difficulty in opening the mouth or chewing, allergic and/or adverse reaction to

medications and/or materials;

Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss of sensation,

•

numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may

resolve over time, but in some cases may be permanent;

Dry socket (slow healing) resulting in jaw pain that increases a few days after surgery;

•

Sharp ridges or bone splinters may form where the tooth was removed possibly requiring additional surgery;

•

Part of the tooth and/or roots may be left to prevent damage to nerves or other structures;

•

An opening may occur from the mouth into the nasal or sinus cavities;

•

Jaw fracture;

•

I have elected to proceed with the anesthesia(s) indicated below and have been informed of and understand potential risks associated with

anesthesia include but are not limited to:

_________ Local Anesthesia

__________ Nitrous Oxide (Laughing Gas)

__________ Mild / Moderate / Deep Sedation

Allergic or adverse reactions to medications or materials;

•

Pain, swelling, redness, irritation, numbness and/or bruising in the area where the IV needle is placed. Usually the numbness or pain goes

•

away, but in some cases, it may be permanent;

Nausea, vomiting, disorientation, confusion, lack of coordination, and occasionally prolonged drowsiness. Some patients may have an

•

awareness of some or all events of the surgical procedure after it is over;

Heart and breathing complications that may lead to brain damage, stroke, heart attack (cardiac arrest) or death;

•

Sore throat or hoarseness if a breathing tube is used.

•

If I have elected Mild, Moderate, or Deep Sedation (General Anesthesia), I have not had anything to eat or drink for at least six (6) hours prior to my

procedure.

I understand that doing otherwise may be life-threatening. As instructed, I have taken my regular medications (blood pressure

medications, antibiotics, etc.) and/or any medicine given to me by my doctor using only small sips of water. I am accompanied by a responsible

adult to drive me to and from the doctor’s office and he/she will stay with me after the procedure until I am recovered sufficiently to care for myself. I

understand the drugs given to me for this procedure may not wear off for 24 hours.

During my recovery from anesthesia, I agree not to drive, operate complicated machinery or devices, or make important decisions such as signing

documents, etc.

If I am sedated or under general anesthesia during the procedure, I further authorize the doctor to modify the procedure if, in his/her professional

judgment, it is in my best interest.

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Patient Initial ___________