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

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