Cass City, MI 48726
James D. Thomas, DDS, PC
all rights reserved
Consent For Oral Surgery and Dental Extractions
text of the Informed Consent is below. You may download the form in
Adobe Acrobat PDF format by clicking on the image to the right. You
may then print, sign and bring the form to our office.
To view and print the document, you'll need Adobe Acrobat Reader on
your computer. You may click on the Acrobat logo button to download
James D. Thomas, DDS, PC
Informed Consent for Oral Surgery and Dental Extractions
from dental procedures very rarely occur, but it is important
to understand the possibilities both with and without treatment.
surgery (which does include dental extractions) has certain
inherent risks. Those risks include but are not limited to:
bleeding subsides in a few minutes to a few hours. However,
if it continues beyond that, it should receive immediate attention.
and/or swelling may
occur and can last for a few days or even a few weeks. This
is especially true if impacted wisdom teeth are involved and
if you bruise easily.
includes nerves in the lips, the tongue, the cheeks, the floor
of the mouth, etc. The numbness which could occur may
be temporary, lasting just a few days, a few weeks, a few
months. It could possibly be permanent.
this occurs after a tooth extraction and results from the
blood clot not forming properly during the healing time. “Dry
socket” refers to the blood clot being lost from the tooth
socket. A dry socket can be painful, and if it occurs
should be treated by your dentist as soon as possible.
proper sterilization and cleanliness are carefully adhered to,
the human mouth and oral cavity are inherently non-sterile environments.
Infection can occur. Occasionally infection can result in swelling,
fever, malaise, etc. Attention should be received as soon
as possible, especially if fever is present.
mats of the upper teeth are very close to the sinus cavity
in some patients. During extraction or other surgical procedures,
the sinus can be perforated, and it maybe necessary to surgically
to adjacent teeth or fillings. No
matter how carefully surgical and extraction procedures are
performed, adjacent teeth and fillings (especially very large
fillings) can sustain injury.
jaw, root fragments. While
rare, it is possible that jaw, teeth roots, or bone may be
fractured. Sometimes a decision is made to leave a root fragment
especially when removing it would necessitate further surgery
and/or complications. Other times, the decision maybe made
to refer the patient to a specialist for evaluation and/or
are present in the oral cavity. This is a normal condition.
The tissues of the heart (for reasons known or unknown, i.e., rheumatic
fever, etc.) may be susceptible to a bacterial infection
that is transmitted via the blood vessels. Bacterial endocarditis
(otherwise known as infection of the heart) is a very serious
condition. If any heart problems are known or suspected,
the patient agrees to inform the doctor before any treatment
to medication. Reaction
to the medication, anesthetic, or analgesia may occur. Reaction
may also occur in response to any other medications that were
administered or prescribed.
is the patient’s responsibility to seek attention should any
problem arise after the treatment. In addition, the patient’s
responsibility is to diligently follow any and all pre-operative
and post-operative instructions.
nature and purpose of the oral surgery and/or extraction has been
explained to me, and I have had an opportunity to have my questions
answered. I understand that dentistry is not an exact science
and success with oral surgery and/or extractions cannot be guaranteed.
I voluntarily assume the risks, including the risk of substantial
harm which may be associated with any part of this treatment.
In view of the above information, I authorize the doctor and/or
such associates and assistants as necessary to render any treatment
necessary and/or advisable to my dental condition including any
and all anesthetics and/or medications.