Extraction Consent

Name
First Name
Last Name
Patient Information and Consent Form for Tooth/Teeth Extraction #
Local Anesthesia:
By receiving local anesthetic, there is a possibility of temporary or permanent numbness of the lip, tongue, chin, cheek, as well as, thrombophlebitis (inflammation of the vein), temporary TMJ problems, and possible allergic reaction.
This field is required.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of their surroundings and able to respond rationally to questionsand directions. I understand I am able to drive myself to and from my appointment.
This field is required.
I have been informed and afforded the time to fully understand the purpose and the nature of the surgery procedure. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. Risks to my health if these teeth are not removed include, but are not limited to: infection, abscess formation, periodontal (gum) disease, increased risk for complications if removal is required at a later time, continued or increasing pain.
This field is required.
I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, dry socket, infection, and discoloration. Temporary or permanent numbness of the lip, tongue, chin, cheek, or teeth may occur. Also possible are thrombophlebitis (inflammation of the vein), injury to teeth present, bone fractures, sinus penetration, delayed healing, TMJ problems, and allergic reactions to drugs or medications used, and in rare cases even death.
This field is required.
I understand that the tooth may need to be sectioned and bone around the tooth may need to be removed to allow for easier removal of the tooth.
This field is required.
I understand that excessive smoking, alcohol, or blood sugar may affect gum healing. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.
This field is required.
I request and authorize medical/dental services for myself, including surgery. I fully understand the contemplated procedure, surgery, or treatment conditions that may become apparent, which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve of any modification in design, materials, or care, if it is felt this is in my best interest.
This field is required.
To my knowledge, I have given an accurate report of my physical and mental health history, including any allergies. Please inform us if you are currently taking or have ever taken medications for osteoporosis (i.e. Fosamax) or chemotherapy as they can affect healing. Please inform us if you are currently taking blood thinners.
This field is required.
Ridge Preservation (Bone Graft): Collagen based bone filling augmentation material to be used to fill the socket following tooth extraction, to preserve bone surrounding teeth.
This field is required.
Patient Name
First Name
Last Name
Patient/Guardian Signature
Signature is mandatory.
Date
Witness
Witness Name

Name
First Name
Last Name
Patient Information and Consent Form for Tooth/Teeth Extraction #
Local Anesthesia:
By receiving local anesthetic, there is a possibility of temporary or permanent numbness of the lip, tongue, chin, cheek, as well as, thrombophlebitis (inflammation of the vein), temporary TMJ problems, and possible allergic reaction.
This field is required.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of their surroundings and able to respond rationally to questionsand directions. I understand I am able to drive myself to and from my appointment.
This field is required.
I have been informed and afforded the time to fully understand the purpose and the nature of the surgery procedure. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. Risks to my health if these teeth are not removed include, but are not limited to: infection, abscess formation, periodontal (gum) disease, increased risk for complications if removal is required at a later time, continued or increasing pain.
This field is required.
I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, dry socket, infection, and discoloration. Temporary or permanent numbness of the lip, tongue, chin, cheek, or teeth may occur. Also possible are thrombophlebitis (inflammation of the vein), injury to teeth present, bone fractures, sinus penetration, delayed healing, TMJ problems, and allergic reactions to drugs or medications used, and in rare cases even death.
This field is required.
I understand that the tooth may need to be sectioned and bone around the tooth may need to be removed to allow for easier removal of the tooth.
This field is required.
I understand that excessive smoking, alcohol, or blood sugar may affect gum healing. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.
This field is required.
I request and authorize medical/dental services for myself, including surgery. I fully understand the contemplated procedure, surgery, or treatment conditions that may become apparent, which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve of any modification in design, materials, or care, if it is felt this is in my best interest.
This field is required.
To my knowledge, I have given an accurate report of my physical and mental health history, including any allergies. Please inform us if you are currently taking or have ever taken medications for osteoporosis (i.e. Fosamax) or chemotherapy as they can affect healing. Please inform us if you are currently taking blood thinners.
This field is required.
Ridge Preservation (Bone Graft): Collagen based bone filling augmentation material to be used to fill the socket following tooth extraction, to preserve bone surrounding teeth.
This field is required.
Patient Name
First Name
Last Name
Patient/Guardian Signature
Signature is mandatory.
Date
Witness
Witness Name