Informed Consent for Extractions

I have been informed that the purpose of removing my tooth/teeth is:

Alternative Treatment:

The following reasonable alternatives to implants have been explained to me:

  • Retaining tooth/teeth as is.
  • Retaining tooth/teeth with the use of fillings/crowns/bridges and if necessary, root canal therapy.
  • Retaining tooth/teeth with the use of gum surgery.

Surgical Procedures may involve some, or all, of the following:

  • Use of local anesthetic, oral or intravenous sedation, antibiotics, analgesics, and sutures (stitches).
  • Use of a bone graft to preserve the bone on neighboring teeth or to provide sufficient bone volume for a future implant. The bone may be my own bone, human donor bone, or cow bone.

Risks and Complications of extraction and bone graft (if applicable):

I understand that the risks and complications include, but are not limited to:

  • Allergic reactions to dental materials/medications
  • Bleeding, swelling, infection
  • Pain and/or tooth sensitivity
  • Bruising
  • Perforation of upper jaw sinus or nasal cavity
  • Bone fracture
  • Scarring
  • Damage to other teeth/roots — which may need repair or removal
  • Damage to dental appliances
  • Cracking/stretching corners of mouth
  • Cuts inside mouth or on lips
  • Slow healing
  • Temporary restriction of mouth opening
  • Stress or damage to jaw joints (TMJ)
  • Increased tooth/teeth mobility of neighboring teeth
  • Possible altered or loss of sensation due to dental nerve damage (teeth, gums, lips, tongue, cheeks, face, palate, chin), including loss of taste which may resolve over time, but in some cases may be permanent
  • Dry socket
  • Bony ridges or splinters that may require further treatment
  • Part of tooth and/or roots may be left to prevent damage to nerves or other structures
  • Nerve injury in the place the graft was taken from or where it is placed if applicable
  • Rare chance of disease spread from processed bone
  • Failure/infection of the bone graft

Risks and Complications of local anesthetic use:

I understand that the risks and complications associated with the use of local anesthetic include, but are not limited to: Nerve injury, resulting in altered or loss of sensation, numbness, pain, or altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue (including loss of taste). Such conditions may resolve, but in some cases may be permanent.

No Warranty or Guarantee:

I understand that the doctor cannot guarantee the results of the procedure.

Consent to Unforeseen Conditions:

During treatment, unknown conditions, such as discovery of changed prognosis for adjacent structures or teeth, may modify or change the original treatment plan. I therefore authorize the treating dentist to do additional or alternative procedures if, in his/her professional judgment, it is in my best interest.

Compliance with Self-Care Instructions:

In order to increase the chance of achieving optimal results, I have provided an accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications, any allergies, recreational drug use, and pregnancy (if applicable).

I understand that excessive smoking and/or alcohol intake may affect healing and may limit the successful outcome of my surgery.

I agree to follow all instructions provided to me by this office before and after the procedure, take medication(s) as prescribed, practice good oral hygiene, keep all appointments, make return appointments if complications arise and complete care. I will inform my doctor of any post-operative problems as they arise. My failure to comply could result in complications or less than optimal results. Supplemental Records and Their Use: I consent to photography, filming, recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures or publications,

provided my identity is not revealed. Patient’s Endorsement:

My endorsement (signature) to this form indicates that I have read and fully understand the terms and words within this document and the explanations referred to or implied. After thorough deliberation, I give my consent for the performance of any and all procedures related to extraction and bone grafting as presented to me during the consultation and treatment plan presentation by the dentist.

You or your responsible party will have the opportunity to sign an electronic copy of this form when you arrive at our office for your appointment. :

Consent

Name of Guardian*
Patient Name*
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By signing the consent section of this patient consent form, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.
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