TOOTH EXTRACTION CONSENT FORM (PLUS CONSENT FOR ANESTHESIA AND BONE GRAFT PLACEMENT)

Information for dentist regarding tooth extraction consent form

This document contains a free to download and use tooth extraction consent form. The form is provided complimentary for use by dentists, oral surgeons or other dental specialists. It is provided courtesy of dentaldecider.com. The document can be downloaded as a pdf file or if you prefer simply edit and paste directly off of our website.

Guidelines for using tooth extraction consent form

All of our consent forms are free to download and use for dentists and dental specialists. You have the option of downloading the pdf file and directly using it as is. Or you can copy, paste this document and make appropriate changes better suit your needs.

You assume all responsibility for using the tooth extraction consent form and all of its content. It is your sole responsibility to verify the validity of any and all information provided herein. You hereby agree to release dentaldecider.com from all liabilities whatsoever which may arise as a result of using this consent form.

If you have any suggestions to improve our consent forms please email customer service at customerservice@dentaldecider.com. We would great appreciate it! Good luck and enjoy dear colleagues.

TOOTH EXTRACTION CONSENT FORM (PLUS CONSENT FOR ANESTHESIA AND BONE GRAFT PLACEMENT)

presented by dentaldecider.com in conjunction with Toothy Lane

This is an informed consent form to better inform patients of risks and benefits associated with tooth removal surgery. First, it discusses risks and benefits of anesthesia and sedation prior to removing the teeth. Next it discusses the pros and cons or a placing bone graft after removing your teeth. Finally, it discusses the benefits and risks of removing your teeth. Please read carefully and initial and sign where indicated. If you have any questions please ask your dentist before signing off on this consent form.

TEETH NUMBER(S) SCHEDULE FOR EXTRACTION:

Teeth number(s): _____________________________________________

Patient initial: _________

ANESTHESIA CONSENT

____________ (patient initial) I understand that my dentist will be using local anesthetic along with epinephrine to numb up my teeth prior to removing them. I am aware of the risks and complications that are associated with using local anesthetics along with epinephrine. Risks include pain, allergic reaction, hematoma, elevated blood pressure, dizziness, fainting as well as anaphylactic shock (in rare cases).

Additionally, I have also been made aware of various methods to relieve anxiety prior to tooth extraction surgery. I hereby consent to the following form of sedation being used in conjunction to local anesthetics (please initial next to your preferred option if any):

_________ Nitrous Oxide which involves inhaling nitrous oxide gas during surgery. Risks include nauseousness, vomiting, dizziness in addition to risks of local anesthetic.

_________ Pre-medication with anti-anxiety medication which involves taking one or a few anti-anxiety pills prior to surgery. Risks include severe disorientation, excessively long lasting effects, overdose which can result in death in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

_________ Intravenous (IV) Sedation which involves injection of drugs into the arm to achieve a higher level of disorientation known as deep sedation. Risks include agitation, ineffectiveness, overdose which can result in breathing suppression and possibly morbidity in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

_________ General Anesthesia which is the highest level of sedation and can only be performed within the operating room in a hospital setting. Risks include prolonged disorientation and overdose which can result in breathing suppression and possibly morbidity in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

BONE GRAFT CONSENT

____________ (patient initial) I understand that there will be a hole left behind after removing my tooth. I have been made aware whether or not bone graft is a good option to help fill in the void created by tooth extraction for my particular case. My dentist or dental staff have explained to me how bone graft is made and placed. I have read and understand the risks and benefits of using bone graft after tooth removal.

BENEFITS OF BONE GRAFT PLACEMENT
  • I understand that a bone graft is highly recommended if I want to better preserve my jawbone following tooth extraction.
  • I understand that placing bone graft usually helps expedite the healing process.
  • I understand that without bone graft my chances of receiving a dental implant decreases significantly in the spot where I am removing my tooth.
RISKS OF BONE GRAFT PLACEMENT
  • I understand that placing bone graft after tooth removal is an elective process and is not mandatory. 

  • I understand that bone graft may become dislodged and not be as effective.
  • I have been made aware if there are costs associated with placing a bone graft.
  • I understand that placing a bone graft will not in anyway prevent or reduce the risks and complications associated with tooth removal surgery.

Having read the benefits and risks of placing a bone graft, please initial next to your preferred option:

____________  I agree to place bone graft after tooth extraction

____________  I reject placing bone graft at my own risk

TOOTH EXTRACTION CONSENT

____________ (patient initial) I am willingly and consciously giving my dentist informed consent to have my tooth (teeth) removed from my mouth. I understand that there are certain risks and complications associated with this surgery. I have already been informed if these teeth are savable or not. Additionally, I have been informed of options to save the tooth if they are savable. However, I am not interested in saving these teeth and elect to have the tooth (teeth) removed.

BENEFITS OF TOOTH EXTRACTION
  • Eliminates toothache and all problems related to your infected or damaged tooth
  • Eliminates source of infection and gradually rids you of swelling and infection
  • Reduces the possibility of cavity or infection spreading to your other teeth or jaw
RISKS OF TOOTH EXTRACTION
  • Pain after tooth removal surgery. This is the most common complication after teeth extraction. There is no way to tell how long your pain and discomfort will last. It could be days, weeks or months. While pain killers can help, they may not completely eliminate your pain.
  • Infection, swelling and bruising of the surgery site. This is another common tooth removal complication. Taking antibiotics can help but it might not fully eliminate your problem.
  • Excessive bleeding after being dismissed from your extraction surgery. While we try our best to get bleeding under control before dismissing you, this doesn’t always work. You must carefully follow post-operative instructions to help get bleeding levels under control. However if you get home and bleeding doesn’t stop, then you must contact your dentist immediately or otherwise go to an emergency room for further treatment.
  • Drug reactions, either to medication administered for surgery or those which aid recovery.
  • Difficulty eating, chewing or even breathing for a while after your surgery.
  • Accidental damage to the rest of your oral region. This can include laceration to your tongue, stretching of corners of mouth, cheek bruising and other traumas.
  • Accidental damage to adjacent teeth, particularly if these teeth already have a filling or crown. If adjacent teeth sustain any damage this will require additional dental work. Unfortunately, your dentist can not be held responsible for this and you have to fix these problems later at your own expense.
  • Dry socket which refers to delayed healing of tooth extraction site. This requires additional followup and treatment for weeks or even months. Following post-op instructions can help reduce the possibility of developing a dry socket, however it can happen even when in full compliance.
  • Jaw problems (Temporomandibular Joint or TMJ) known as Trismus. TMJ problems include limited opening of your jaws and soreness in the region. These symptoms may alleviate gradually over the course of a few months or they may be indefinite. Follow instructions and followup with your dentist for quicker recovery.
  • We may end up being unable to remove the entire tooth. While we always do our best to try and remove the whole tooth, we don’t always succeed. Should this occur we will first and foremost inform you of the fact that there is still some tooth left behind. Then we will decide if it’s best to remove this tooth fragment or just leave it behind and continue to monitor it. If it’s decided that removal is your best option then you will have to be referred out to an appropriate dental specialist. This is an inherent risk with any tooth extraction and we can not guarantee that we will succeed in removing your tooth every single time.
  • Damage to your jaw nerves. Having temporary numbness after tooth removal is not uncommon. Particularly when removing lower teeth. This numbness and tingling sensation usually subsides after several weeks. However you must followup with your dentist so they can monitor your recovery or refer you to an appropriate specialist if needed. Keep in mind that while rare, occasionally nerve damage can not be repaired. While unfortunate, this is a risk that exists with teeth removal.
  • Damage to your sinus membrane. Occasionally your sinus membrane will tear during tooth extraction surgery. This is mostly associated with upper molar teeth. This requires follow ups and medications until the issue resolves itself. However if it doesn’t repair on its own, you may require a sinus surgery to close the perforation. While unfortunate, this is another risks that is associated with teeth removal.
  • Additional followup surgeries may be indicated. In addition to the aforementioned complications, sometimes a sharp piece of bone is left behind. Should you and your dentist both fail to catch this sharp piece of bone at the time of surgery, it can bother you in the future. A second surgery will be required to smooth out this sharp bone, known as an alveoloplasty.
  • While extremely rare, jaw fracture can also occur as a result of complicated tooth removal surgeries. This will require additional surgery(s) and possibly require wiring your mouth shut for an extend period of time.

I consent that I have thoroughly read and fully understand everything listed above.I understand that dentistry is not an exact science and that there are no guaranteed results. Additionally, I have asked any other question and have received a satisfactory answer. I am prepared to have my tooth removed with the full understanding of all possible risks and complications associated with this surgery.

Patient name: ______________________________________

If minor, guardian name:  _____________________________________

Relationship to patient (minors only): ____________________________

Patient (or legal guardian) signature: ____________________________

Date : ________________

Witness name: _________________________________________________

 Witness signature: __________________________________________________

Date : ________________

 

Doctor name: ____________________________________________________  

Doctor signature: __________________________________________________

Date : ________________

How smart people decide on a dentist

Show Buttons
Hide Buttons