Extraction Informed Consent Form

Patient name:
I hereby authorize (Doctor's name) and any associates to perform anExtraction on tooth/teeth number(s):

I understand that there MAY be alternatives to the extraction of these tooth/teeth.

After considering the various options, I have chosen extraction.

I understand that there are various normal complications that can occur despite all efforts to the contrary as a result of
the extraction(s) which include but are not limited to:

• Allergic reaction to medications or anesthetics used in the extraction process

• Pain, swelling, infection, bruising, bleeding

• Stiffness of the adjoining or nearby muscles

• Numbness – There is the possibility of injury to the nerves of the face or tissues of the oral cavity during the administration of anesthetics or during the extraction, which may cause a numbness of the lips, tongue, tissues of the mouth and/or facial tissues. This numbness is usually temporary but may be permanent.

• Fracture of the root tips, which may also result in the root tips being left in place or displacement of the root tip into the sinuses and/or spaces nearby.

• I understand that there is a possibility that my tooth might break, resulting in my dentist needing to refer me to a specialist (oral surgeon) to have the tooth removed, which will involve further costs.

• Dry sockets, aspiration and/or swallowing of foreign objects.

• Damage to adjacent teeth and/or restorations I further understand that this procedure can also be performed by a
  specialist and request that this treatment be performed in this office by a general dentist.

The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure.

I may ask the attending dentist for a more complete explanation. This is my consent for the extraction, anesthetics, and
x-rays to be taken.

I have read and understand the above and have had all my questions answered to my satisfaction and I agree to proceed
with the recommended extractions(s).

Patient Signature:
Date: