HSF EXTRACTION CONSENT

Possible complications which have been explained to me include, but are not limited to:

You can expect bleeding, swelling and/or pain following this procedure.

Other possible complications:
• Bleeding and/or bruising which may be prolonged
• Dry Socket or incomplete healing of the extraction site(s)
• Infection
• Injury to nearby teeth, fillings or adjacent structures
• Restriction of mouth opening
• Unusual reaction(s) to medications given or prescribed
• Injury to nerves in or around the mouth that could be permanent
• Sinus openings
• Decision to leave a piece of root in the jaw when its removal would require extensive surgery and increased risks or complications
• Need for a secondary procedure

Alternative to surgery:
• No treatment

Risks to choosing no treatment include, but are not limited to:

• Pain
• Infection
• Cyst and/or tumor formation
• Continuing loss of bone around the teeth
• Increased risk of complications if surgery is postponed

Patient Consent: I agree to the planned treatment above as explained and will allow the below Doctor with Healthy Smiles Forever (HSF) to complete this treatment.

I consent to the use of local anesthetic to “numb” the area prior to tooth removal by HSF. I will follow the instructions for taking care of my mouth after the extraction(s) to the best of my ability, for my own comfort and safety. I have had an opportunity to ask questions regarding these procedures and I feel comfortable that I understand my treatment, possible complications and benefits. I speak English and do not need the services of a translator.