Tooth Extraction Informed Consent (Page 2 of 2) in pdf

TOOTH EXTRACTION INFORMED CONSENT

Patient’s Name: ________________________________________________ Date of Birth: ________________________

BONE GRAFTING (Applicable only if any graft is placed)

The graft will be taken from or will be banked bone or bone substitute: _______________________

The graft will be placed: ________________

I understand the grafting involves additional potential risks, including but not limited to:

Nerve injury in the place the graft was taken from or where the graft is placed resulting in altered or loss of sensation, numbness, pain, or

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changed feeling in the lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve over time, but in some cases

may be permanent;

Failure, loss, infection, or rejection of the graft or membranes used to contain the graft;

•

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

•

If I have elected a banked bone or bone substitute graft, I understand there is a rare chance of disease spread from the processed bone.

•

Patient Responsibilities

I understand that I am an important member of the treatment team. In order to increase the chance of achieving optimal results, I have provided an

accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications,

any allergies, recreational drug use, and pregnancy (if applicable). I agree to follow all instructions provided to me by this office before and after the

procedure, take medication(s) as prescribed, practice proper oral hygiene, keep all appointments, make return appointments if complications arise,

and complete care. I will inform my doctor of any post-operative problems as they arise. My failure to comply could result in complications or less

than optimal results. I understand the use of tobacco and alcohol is detrimental to the success of my treatment.

I have been informed of and understand that follow up visits or care, additional evaluation, treatment or surgery, and/or hospitalization may be

needed.

I understand and accept that the doctor cannot guarantee the results of the procedure. I had sufficient time to read this document, understand the

above statements, and have had a chance to have all my questions answered. By signing this document, I acknowledge and accept the possible

risks and complications of the procedure and agree to proceed.

(Doctor) I certify that I have explained to the patient and/or the patient’s legal representative the nature, purpose, benefits, known risks,

complications, and alternatives to the proposed procedure. The patient and/or patient’s legal representative has voiced an understanding of the

information given. I have answered all questions to the best of my knowledge, and I believe that the patient and/or legal representative fully

understands what I have explained.

Patient or Legal Representative Name/Relationship: _____________________________________________

Date: ______________________

Patient or Legal Representative Signature: ___________________________________________________________________________________

Doctor Signature: ________________________________________________________________________

Date: _______________________

Page 2 of 2

Patient Initial ___________

Tooth Extraction Informed Consent Page 2

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