Extraction of tooth/teeth number(s):

I understand that the extraction of a tooth/ teeth has been recommended by my dentist. I have had any alternative treatment explained to me, as well as the consequences of doing nothing about my dental conditions.

I understand that non treatment may result in, but it is not limited to:

Increased risk of complications 1f delayed
Infection and/ or abscess
Pain and/ or swelling
Periodontal disease
Malocclusion
Need for immediate emergency treatment if symptoms worsen

I understand that there are risks associated with any dental, surgical, and anesthetic procedure. These risks include, but are not limited to:

Bleeding, bruising and/ or swelling which can be significant and prolonged
Pain or discomfort
Infection
Dry socket (painful extraction site with delayed healing, requiring treatment)
Damage to sinuses requiring additional treatment or surgical repair at a later date
Damage to the nerves during tooth removal resulting in temporary, or possibly partial or permanent numbness or tingling of the lip, chin, tongue, or other areas
Fracture or dislocation of the jaw

By signing, I understand the recommended treatment, the fee involved, and the risks of such treatment, any alternatives and risks of these alternatives. I understand the information discussed and have had the opportunity to ask any questions.

Patient Name (Print)

Date

Patient/Parent/Guardian Signature

Dentist Signature

This field should be left blank

Informed Consent for Extraction