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Consent for Extraction

I understand that oral surgery and/or dental extractions include inherent risks such as, but not limited to the following:

1. Injury to the nerves: This would include injuries causing numbness of the lips; the tongue; any tissues of the mouth; and/or cheeks or face. This numbness which could occur may be a temporary, lasting a few days, weeks, months or could possibly be permanent and could be the result of surgery or anesthetic administration. Injuries to the nerve may also result in shooting pain.

2. Bleeding, bruising, swelling: Bleeding may last several hours. Some swelling is normal, but if severe (extending to the eye or neck), you should notify us. Bruises or hematomas may persist for some time.

3. Dry Socket: This occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry socket can be extremely painful if not treated.

4. Sinus involvement: In some cases, the roots of upper teeth lie in close proximity to the sinuses. Occasionally, during extraction and surgical procedures, the sinus membrane may be perforated. Should this occur, it may be necessary to have the sinus surgically closed. Root tips may need to be retrieved through the sinus.

5. Infection: It is possible for infections to occur postoperatively. At times, these may be of a serious nature. Should severe swelling occur; particularly accompanied with fever or malaise, attention should be received as soon as possible.

6. Fractured jaw, roots, bone fragments, or instruments: Although extreme care will be used, the jaw, teeth roots, bone fragments or instruments used in the surgical extraction procedure may fracture or be fractured, requiring retrieval and possibly referral to specialist. A decision may be made to leave a small piece of root, bone fragment or instrument in the jaw when removal may require additional extensive surgery which could cause more harm and add to the risk of complications.

7. Injury to adjacent teeth or fillings: This could occur at times during surgical and or extraction procedures.

8. Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, the tissues of the heart, as a result of reasons known or unknown may be susceptible to bacterial infection transmitted through blood vessels, and bacterial endocarditis (an infection of the heart) could occur. It is my responsibility to inform the dentist of any heart problems known or suspected.

9. Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may occur from anesthetic or other medications administered or prescribed. All prescription drugs must be taken according to instructions given. Women using oral contraceptives must be aware that antibiotics can render these oral contraceptives ineffective. Other methods of contraception must be utilized during antibiotic treatment period.

10. It is my responsibility to seek attention should any undue circumstanced occur post-operatively and I shall diligently follow any post-operative instructions given to me.

Informed Consent: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and/or extraction of teeth and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize

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