DENTAL EXTRACTION CONSENT FORM
Current standard of care in dentistry requires that I obtain your informed consent prior to performing an extraction(s). What you are being asked to sign is a confirmation that I have discussed your contemplated procedure, and I have informed you of all risks, benefits, and ramifications of this procedure, all alternative treatments with their risks and benefits.
I understand that the extraction of a tooth (teeth) has been recommended by 209 NYC Dental. I have had any alternative treatment (if any) explained to me, as well as the consequences of doing nothing about my dental conditions. I understand that non-treatment may result in, but not be limited to: infection, swelling, pain, periodontal disease, malocclusion, (damage to the way the teeth hit together) and systemic disease/infection.
I understand that there are risks associated with any dental, surgical, and anesthetic procedure. These include, but are not limited to:
Pain, discomfort, bruising, bleeding, swelling, sore throat or difficulty swallowing, (any or all possibly severe at times) necessitating several days or weeks or home recuperation.
Postoperative infection that may require additional treatment, possible hospitalization.
Allergic reactions (previously unknown) to any medications used in treatment.
Injury to adjacent teeth and gums or loss or loosening of fillings and caps.
Sensitivity of adjacent teeth to cold food and liquids for weeks or months.
Stretching or abrasion of the lips or corners of the mouth resulting in soreness, pain, difficulty opening, and eating - (lasting several days or weeks).
Trismus (restricted mouth opening) lasting several days or weeks.
Swallowing or aspiration (breathing in) of part of a tooth, filling or debris.
Temporomandibular joint (jaw joint) dysfunction and pain.
Weakening or fracture of the jaw or part of the jaw (alveolar process, tuberosity) surrounding the tooth.
For upper teeth – opening into the sinus or nasal cavity or sinus complications or infection possibly requiring a second procedure possibly with additional costs.
Numbness (loss of feeling) of the lip(s), chin, cheek(s), face, gums, and/or tongue with loss of taste, that usually resolves in weeks or months but could remain permanently.
Decision to leave small root tip in the jaw when its removal could require extensive surgery or risk other complication such as damage to the nerve or the sinus.
Bone spicules (particles), root fragments, sharp edges of bone or food debris causing irritation, pain, swelling or infection presenting days or weeks after surgery.
Dry socket (loss of blood clot from extraction site) or painful socket that may require additional care.
Other:
I certify that the medical history I have given is accurate and complete to the best of my knowledge. By providing my signature, I certify that I understand the recommended treatment, the fee involved, the risks of such treatment, any alternatives and risks of these alternatives, including the consequences of doing nothing. I have had all of my questions answered, and have not been offered any guarantees.
By signing, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.