Form

INFORMED CONSENT FOR TOOTH EXTRACTION

I understand that my dentist has recommended the extraction of one or more tooth. He has explained to me alternative treatment(s) - if any - as well as the consequences of doing nothing about my dental condition. I understand that without treatment I could suffer from the following illness: infection, swelling, pain, periodontal disease, poor occlusion (damage to the way the teeth are against each other), and systematic disease.

I understand that there are risks associated with any dentifrice and anesthetic procedure. These may include, but are not limited to:

Drug reaction and side effects.
Damage to adjacent teeth and fillings.
Infection after an operation.
Aches, bruises, or swelling.
Post-operative hemorrhage that may require additional treatment.
Possibility of leaving a small fragment of root or bone in the jaw when its extraction is not appropriate. such fragments may, by themselves, partially leave the tissue and require treatment later.
Injury to the nerve underlying the teeth resulting in numbness or tingling of the lip, chin, gums, cheek, teeth, and/or tongue on the operated side. this may persist for several weeks, months, or in some remote instances, permanently.
Fracture or dislocation of the jaw.
Nerve damage that results in numbness, or tingling, temporary or possibly permanent, of the lip, chin, tongue or other areas.

I understand the recommended treatment, the risks of such treatment and any alternatives and risks, and all the costs involved as well as the consequences of doing nothing. They have answered all my questions and have not offered me any guarantee.

Procedure: Extraction(removal) of tooth/teeth #

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