Extraction Consent Form:
I fully understand that there are certain inherent and potential risks associated with any type of surgical treatment including extractions. I understand that following treatment I may experience pain, or discomfort, bleeding, swelling, bruising, and stiff jaws, all of which may last for several days. I understand that it is possible for an infection to occur in the extraction site and that I may need antibiotics and or other procedures to treat the infection. I understand that less common complications include dry socket (lost blood clot), loss or loosening of dental restoration, loss or injury to adjacent teeth and soft tissues, jaw fractures, sinus exposure (upper teeth) as well as swallowing or aspiration of teeth and restorations. I understand that small root fragments may break off from the tooth being extracted. Depending on their size and position they may either be left to remain in the jaw or may require additional surgery for removal.
I understand that during surgery it may be impossible to avoid touching, moving and stretching or injuring the nerves in my jaw that control sensations and function in my lips, tongue, chin, teeth and mouth. This may result in nerve disturbances such astemporary or permanent numbness, itching, burning, or tingling of the lip, tongue, chin, teeth and or mouth tissues. I understand that extracting my tooth may not relieve symptoms and that complications may occur. Other treatment procedures maybe necessary. I understand that I will be given a local anesthetic injection and in rare instances patients could experience temporary or nerves and or blood vessels from injection. I understand that injection areas may be uncomfortable following treatment and that my jaw may be stiff and sore from holding my mouth open during treatment.
I understand that this procedure can also be performed by an oral surgeon (a dental specialist). I understand the risks and elect to have this procedure done by Dr. Augustyn/Dr. Singh. I understand that if any unexpected difficulties occur during treatment, I may be referred to an oral surgeon for further care.
Simple/Surgical Extraction:
Extraction involves the complete removal of a tooth from the mouth. Some extractions may require cutting into the gums and removing supporting bone and/or cutting the tooth into sections prior to removal. The benefit of the extraction is to relieve my current symptoms and or to permit me to continue with any additional treatment my dentist has proposed.
I am being provided with this information so I may better understand the treatment recommended for me. I understand that I may ask any questions I wish.
I have provided an accurate and complete medical and personal history. I will follow any and all treatment and post treatment instruction as explained and directed to me. I realize that in spite of the possible complications and risks, my recommended treatment is necessary.