Consent of Extraction Form - Walk In Family Dental

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Patient Information

Name*

Date*

Consent of Extraction

Date*

Patient Name*

authorize the following procedure(s) and treatment on myself the removal of the following teeth#

Teeth#*

Consent*
I agree to the Consent.
with or without sedation ( oral / N20 / IV )or whoever he may designate to perform the procedure . A responsible escort must accompany me to and from appointment if I am to be under sedation . If sedated I am considered impaired for at least 24 hours after surgery . The nature and purposes of the treatment , possible alternative methods of treatment the risks involved and the possible complications have been explained to as follows :

1. Pain : Medication will be prescribed to keep discomfort under control.

2. Dry Sockets : Possible painful inflammation of the jaw bone following extraction. This usually happens if the blood within the healing socket is disrupted ( ie : smoking , sucking through straws should be avoided , bisphosphonate meds to treat osteoporosis ).

3. Maxillary Sinus Perforation : Perforation of the maxillary sinus floor may result if the upper teeth roots are in close proximity to the sinus floor.

4. Bleeding : Minimal bleeding from the extraction site is normal following the first 24 hours after extraction . Any bleeding disorder and medication such as blood thinner can cause excessive bleeding so your dentist must be informed of any such condition medications.

5. Paresthesia : Nerve damage is uncommon but possible depending on the proximity of the teeth to the nerve ( lingual nerve , inferior alveolar nerve ) . Damage to the nerve may cause temporary numbness to the lower lip / chin , tongue and possible other regions that may last weeks or months . Sometimes the damage to the nerve however , may lead to permanent numbness to these areas.

6. Damage to the teeth : This is possible especially if these teeth have cavities or are structurally compromised.

7. Remaining pieces of the tooth / root / bone : Root tips may break and remain in bone especially if the roots are curved . These pieces may eventually be exfoliated ( removed ) by your jaw.

8. Some other complications include infection , edema ( swelling ) , and even bone fracture.

Dentist*

SIGNATURE OF PATIENT (or Legal Guardian)*

SIGNATURE OF DENTIST*

INSTRUCTIONS FOLLOWING ORAL SURGERY

1. Bite on gauze for 30 minutes (1/2 hour)
2. Keep fingers and tongue away from the operated area.
3. Do not rinse your mouth until tomorrow, although it is permissible to drink cool or lukewarm liquids.
4. Smoking should be avoided.
5. Starting tomorrow rinse your mouth frequently with a solution of 1/2 teaspoon of salt in a glass of warm water (Continue the rinses for a few days).
6. If you have any discomfort, take whatever you normally take for a headache every few hours. If necessary the doctor will prescribe stronger medication.
7. Diet cold or lukewarm liquids may be taken for the first 4-6 hours after this any soft food is permissible.
8. Bleeding it is normal for the saliva to be streaked with blood for a day if frank Bleeding present fold sterile gauze into a firm wad and place it directly on the bleeding area. Maintain firm pressure by biting for 20 minutes.
9. Swelling and discoloration is to be expected in certain areas, usually reaching its maximum two days after the surgery. It will disappear gradually and is no cause for concern if desired, an ice pad may be applied for the first 4-6 hours only alternating 20 minutes on. 20 minutes off.
10. Sutures (stitches) if required are removed without discomfort in about 5 days.
11. Do not hesitate to call the office if you any question.

Date*
MM slash DD slash YYYY

SIGNATURE OF PATIENT (or Legal Guardian)*