Informed Consent for Oral Surgery

Informed Consent for Oral Surgery
Procedure: Extraction of Teeth
Other Explanation
Alternative to Extraction
The patient should understand that, if this tooth(teeth) is(are) not treated as stated above or extracted, his/her condition may worsen and results in complications, including but not limited to:
- Increased Infection
- Loss of Additional Teeth
- Pain
Possible Complications of extration of teeth include:
- Infection
- Dry Socket
- Bleeding and Bruising
- Swelling
- Decision to leave a small root tip if extensive surgery is required to remove it
- Injury or fracture to adjacent teeth, filling, or crown and bridges
- Sinus involvement (oral/antrul communication) with extraction of upper teeth
- Parasthesia (Numbness) of the lip and/or palate with extraction
- Fracture of the jaw
I have discussed the surgery and consent to the surgery as described.
Tooth # or #'s
Date

MonthDayYear
Date
Patient or Parent / Guardian Full Name

First NameLast Name
Patient or Parent/Guardian Signature
Attending Dentist Full Name

First NameLast Name
Attending Dentist Signature
Witness Full Name

First NameLast Name
Witness Signature
Should be Empty: