Oral surgery (extraction)
I fully understand this consent for surgery and the reasons why the recommended treatment is necessary. I have been given the opportunity to ask questions regarding the recommended treatment and have been given satisfactory answers. I understand that no guarantee regarding the treatment has been made or implied.
TREATMENT: __________________________________________________________ _______________________________________________________________________
B. TREATMENT ALTERNATIVES I elected the treatment listed above even though the following alternatives have been explained to me as being both practical and possible.
TREATMENT ALTERNATIVES: ___________________________________________ ________________________________________________________________________
C. ANESTHESIA/MEDICATIONS I also authorize the recommended treatment to be performed with the following anesthetics and/or medications: _____ Local anesthesia only _____ Local anesthesia with nitrous oxide and oxygen
D. RISKS AND CONSEQUENCES I understand that there are risks associated with the administration of medications and performance of the recommended surgery such as the items check below:
_____ Drug reactions and side effects
_____ Post-operative bleeding and pain
_____ Necessary removal of bone during tooth extraction
_____ Post-operative infection or bone inflammation
_____ Possible damage to the sinus when upper back teeth are removed which may require surgical repair at a future date
_____ Possible nerve damage when lower wisdom teeth are removed which can result in either temporary or permanent tingling or numbness in the lower lip
_____ Fracture of the mandible
_____ Jaw joint (TMJ) pain, malfunction and/or difficulty in opening mouth due to muscle spasms, following removal of lower teeth
