Consent for Tooth Extraction

The extraction of any tooth in the mouth is considered a minor oral surgery and as such has some inherent risks to the surrounding tissues. The possible complications relate to the position the tooth is in the mouth. Generally, when a tooth is extracted there can be damage to the adjacent tooth including fracture and broken filling. Regarding upper molars there can be fracture of the supporting bone, root dislodgement into the sinus and possible sinus communication.

You must inform the dentist prior to treatment if you have a coagulation condition, heart condition, or are taking any medications such as bisphosphanates or blood thinners including aspirin. Any further treatment required by an Oral and Maxillofacial Surgeon or another health practitioner will be at your cost.

The dentist will select patients to treat and manage accordingly. The dentist will endeavour to provide you with the best possible care for each situation. Please discuss any concerns about any procedure with the dentist before agreeing to have the procedure completed. You have options for treatment under local anaesthesia, sedation and under a general anaesthetic in a hospital setting. Please note treatment at the hospital will incur further costs.

Your Consent

The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents/guardians) to understand and give permission for elective dental surgery. Each item needs to be agreed to after the patient (and/or parents/guardians) has the opportunity for discussions and questions.
First Name
Last Name
Date of Birth
I understand and agree to the planned treatment. I consent to the following tooth/teeth to be extracted *
Agree
Disagree
Please nominate which tooth/teeth are to be extracted (please refer to chart above to nominate tooth/teeth to be extracted)
The reasons and benefits of having extraction/s have been explained to me. My Dentist has explained the effect and nature of the proposed treatment to me. *
Agree
Disagree
I consent to the administration of local anaesthesia for this procedure and have informed my Dentist of any reactions I have had to adrenalin in the past. *
Agree
Disagree
I have been informed of possible risks and complications which include, but are not limited to: Pain and swelling Bleeding Infection Injury to the present teeth, and/or adjacent teeth Bone fractures Sinus penetration Delayed healing Dry socket Allergic reactions to drugs or medications used Altered taste sensation and numbness of the lip, tongue, cheek or teeth Boney protrusions (high spots on the gum) which may require bone filling/removal *
Agree
Disagree
I accept and understand that long-term post-operative monitoring may be required and cooperation in keeping scheduled appointments is important. Regular dental check-ups with your Dentist are important to monitor and attempt to prevent break down in your oral health. *
Agree
Disagree
I agree to follow the post-operative instructions given to minimise complications. I understand that smoking is likely to negatively affect post-operative healing. *
Agree
Disagree
I understand the importance of my medical history and affirm that I have informed my Dentist of my medical conditions and current medications. I understand that failure to give true health information may adversely affect my care and lead to unwanted complications. *
Agree
Disagree
I realise that, despite all precautions that may be taken to avoid complications, there can be no guarantee as to the result of the proposed treatment. *
Agree
Disagree
I accept the estimation of the fees as provided and agree to pay the final fee on the date of service or prior. *
Agree
Disagree
I certify that I speak, read and write English and have had my questions answered. I have read and fully understand this consent for surgery. *
Agree
Disagree

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