Consent for Extraction of Teeth | Lunar Smile Dentistry

Patient

Patient first name

Patient last name

Date of birth

Month

Day

Year

Tooth or teeth to be removed

Reason for removal

As discussed with your dentist. Check all that apply.

Reason for removal

Common reasons for removing a tooth include:

infection or abscess;
gum (periodontal) disease;
a tooth that cannot be restored;
orthodontic reasons; or
another reason your dentist explains to you.

If the tooth is not removed

Infection can continue, grow and spread.
A spreading infection can become serious, causing fever and illness throughout the body and, very rarely, becoming life-threatening.
A loose tooth or broken pieces of tooth can be inhaled or swallowed.

Possible complications

These are uncommon, but can happen during or after an extraction:

pain, swelling and bruising;
damage to nearby teeth, fillings, crowns or gums;
nerve injury causing numbness or tingling of the lip, chin or tongue, usually temporary but occasionally permanent;
dry socket, a painful but non-infected delay in healing of the socket;
infection;
reactions to medications, anaesthetic or materials used;
a small piece of root being left in place when removing it would do more harm than good;
an opening into the sinus when upper back teeth are removed, which may need further treatment; and
rarely, a fracture of the jaw that needs further treatment.

Other options

Removing a tooth is a choice, and it is often not the only one. Depending on the tooth, alternatives can include root canal treatment and a restoration, gum treatment, or no treatment for now. If you go ahead, options for replacing the tooth, such as an implant, bridge or denture, can be discussed.

Aftercare

Follow the spoken and written aftercare instructions you are given, and return for a follow-up visit if we ask you to.

Please tick each statement to confirm it is true for you

I have read this form, or had it read to me, and I understand it.My dentist has explained the procedure, why it is recommended, the possible risks, and the other options available to me, including no treatment.I have had the chance to ask questions, and my questions have been answered to my satisfaction.I understand that dentistry is not an exact science and that no particular result has been promised or guaranteed to me.I have given an accurate and complete health history, including medications, allergies, past reactions, and pregnancy if applicable.I will follow the aftercare instructions I am given and return for follow-up if asked.I consent to removal of the tooth or teeth listed above. If something unexpected is found during treatment, I allow my dentist to do what is reasonably necessary in my best interest, and I understand this will be discussed with me whenever possible.

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