Extraction Consent Patient Name and/or Chart Number: Your dentist suggests that the following teeth be removed: For the following reason(s): Abscess Periodontal disease Non restorability Other The consequences of not performing necessary extractions may include: Continuation, growth, and/or spread of infection Pain and swelling Systemic infection, such as fever, sepsis, and (in rare cases) death Aspiration (inhaling) of loose teeth or tooth fragments Though rare, the following complications may occur during or after dental extractions: Pain and swelling Injury to neighboring teeth, restorations, or soft tissues Reversible or irreversible nerve damage Dry socket (a painful, noninfectious complication) Infection Adverse reactions to medications, anesthesia, or substances used for the extraction Retained fragments of teeth in the jaw (if the risk of removal outweighs the benefit) Perforation of the maxillary sinus, possibly requiring further treatment In rare cases, fracture of the jaw requiring further treatment I understand that tooth extraction is an elective procedure, and there are often alternative treatments, such as a root canal and restoration or performing no treatment at all. My dentist has described other options, invited me to ask questions, and I am electing to proceed with the extraction. I will follow the verbal and written postoperative instructions and return for a follow-up appointment if requested.Patient or Guardian Name: Patient or Guardian Signature:Date: MM slash DD slash YYYY Name of provider: Signature of provider:Date: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
