Extraction & Surgical Extraction Consent Form

First Name*

Last Name*

Date of Birth

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I understand and agree to the planned treatment. I consent to the following tooth/teeth to be extracted * 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 *

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. * 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. * 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 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. * 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. * 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. * 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. * 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. * 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. * 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