Steeles McLaughlin Family Dentistry

Extraction Consent Form

18-545 Steeles Avenue West, Brampton, ON, L6Y 4E7      905-455-2023

Patient's Name:
E-mail Address

Informed Consent for Oral Surgery

Procedures

Extraction of tooth/teeth number(s):

Alternatives to Surgery: Risks of the above not being performed include but are not limited to:

  1. Infection
  2. Cyst or tumor formation
  3. Periodontal (gum) disease
  4. Increased risk for complications of removal is required later time

Possible Complications which have been discussed with me include but are not limited to:

  1. Injury to the nerves, to lower lip, and tongue causing numbness that can be permanent or temporary
  2. Bleeding which may be prolonged and/or bruising, discoloration of skin
  3. Dry Socket (blood clot dislodging from extraction socket leading to pain)
  4. Involvement of the sinus in case of removal of the upper teeth
  5. Infection, pain, discomfort in the area of surgery requiring further treatment
  6. Decision to leave a small piece of root in the jaw when it's removal would require extensive surgery and increased risk of complications especially in areas close to the nerves or sinuses
  7. Injury to adjacent teeth or fillings, Crown-Bridge
  8. Unusual reaction to medications given or prescribed
  9. Trismus: limited mouth opening especially after wisdom teeth removal due to swelling and inflammation
  10. Sharp ridges or bone splinters that may form later at the edge of the socket, which may need a surgery later to remove or smooth them

Most procedures are routine and serious complications are not expected those that do occur are minor and can be treated easily.

Patient Consent

Signature