Dental Extraction Consent Form

What Is a Dental Extraction Consent Form?

By providing their signature on the tooth removal consent form, the patient certifies that they have been informed about the fee involved, understand the recommended treatment, know about the risks of such treatment, and any alternatives and risks of the alternatives, as well as the consequences of doing nothing. The patient then agrees to have had all of their questions answered, and admits they have not been offered any guarantees.

The Consent Form for dental extraction usually mentions such dental conditions of non-treatment as infection, swelling, and pain. It can also include dental diseases, like periodontal disease, malocclusion, and systemic infection. The risks associated with any dental, surgical, and anesthetic procedure include, but are not limited to any of the following:

1. Infection or inflammation.
2. Swelling, bruising, and pain.
3. Damage to the adjacent teeth or fillings.
4. Drug reactions and side-effects.
5. Bleeding that sometimes results in emergency treatment.
6. The possibility that a small fragment of root or bone will be left in the jaw intentionally or unintentionally.
7. Delayed healing (dry socket), which sometimes means several post-operative visits.
8. Damage to sinuses that requires treatment at a later date.
9. Fracture or dislocation of the jaw.
10. Damage to the nerves during tooth removal. This damage can result in a temporary, partial, or permanent numbness of the lip, chin, tongue, or other facial areas.

As to post-operative care, the patient agrees to refrain from smoking and spitting for 3 days, as well as from drinking through a straw for 3 days. Any kind of heavy exertion is not recommended for 3 days after tooth extraction and the patient agrees to these terms by signing the form.

Related Forms and Templates:

• Medical Consent Form;
• HIPAA Consent Form;
• Child Travel Consent Form.