Extraction Consent Form

EXTRACTION CONSENT FORM
Name*
First Name Last Name
Today's Date*
DD slash MM slash YYYY
Tooth extraction is an irreversible process and, whether routine or difficult, it is a surgical procedure. As with any surgical procedure, there are potential risks. In this instance, such operative risks may include, but are not limited to:
1) Swelling and/or bruising and discomfort in the surgery area.
2) Stretching of the corners of the mouth resulting in cracking and bruising.
3) Possible infection requiring further treatment.
4) Dry Socket – jaw pain beginning a few days after surgery, usually requiring additional care. It is more common from lower extractions, especially wisdom teeth.
5) Possible damage to adjacent teeth, especially those with large fillings or caps.
6) Numbness or altered sensation in the teeth, lip, tongue and chin, due to the closeness of tooth roots (especially wisdom teeth) to the nerves which can be bruised or injured. Sensation most often returns to normal, but in rare cases, the loss may be permanent.
7) Trismus – limited jaw opening due to inflammation or swelling, most common after wisdom tooth removal. Sometimes it is a result of jaw discomfort (TMJ), especially when TMJ symptoms already exist.
8) Bleeding – significant bleeding is not common, but persistent oozing can be expected for several hours.
9) Sharp ridges or bone splinters may form later at the edge of the socket. These may require another surgery to smooth or remove them.
10) Incomplete removal of tooth fragments: to avoid injury to vital structures such as nerves or sinuses, sometimes small root tips may be left in place.
11) Sinus involvement: the roots of upper back teeth are often close to the sinus and sometimes a piece of root can be displaced into the sinus, or an opening may occur into the mouth which may require additional care. For this reason, it is important to avoid hard nose-blowing for at least 2 weeks after the surgery so as not to forcibly create a hole between the sinus and the mouth.
12) Jaw fracture: while quite rare, it is possible in difficult or deeply impacted teeth. Additionally, contact sports should be avoided for at least 4 weeks.
Most procedures are routine and serious complications do not arise. Those which do occur are often minor and can be treated.
Consent*
Other treatment options (including no treatment) and their consequences have been explained to me. I have had an opportunity ask questions, and have my questions answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I recognize there can be no guarantee as to the outcome of treatment. I understand the above and agree to undergo the procedure.
Tooth Number*
Treatment Provided by:*
Patient/Guardian Signature*

Extraction Consent Form

EXTRACTION CONSENT FORM

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