Pediatric Dentistry of New York

Simple Extraction Consent Form

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has explained the benefits and risks of tooth removal to me. I understand that surgical extraction may be necessary. Referral to a specialist (oral surgeon) has been offered.

I understand and accept the treatment recommended for me by The Doctor. I further understand that there may be some unwanted complications, some of which are listed below. No guaranties have been made or implied.

The Doctor has discussed whether or not the tooth/teeth he has proposed be extracted are impacted to any degree. I understand that an impacted tooth may have begun to erupt in the wrong direction and may be blocked from fully erupting by bone and adjacent teeth. I understand that allowing impacted teeth to remain may result in infection and/or cyst formation, which may destroy bone; damage the roots of adjacent teeth from pressure of the malposed tooth/teeth; and/or create a food trap, which may result in decay. Alternative treatment(s) or the option of no treatment has been explained to me. I understand the risks of not having the extraction(s) performed, whether the tooth/teeth are impacted, partially impacted or not impacted at all, include, but are not limited to: infection; swelling; pain; periodontal disease; malocclusion; and systemic disease. All of my questions have been addressed.

Proposed fees have been explained to me, as have any third party insurance benefits. I understand that third party benefits may be different than discussed by The Doctor, as they are not under the control of this office.

Treatment risks/unwanted consequences may be (but are limited to):
• Reaction to medications/anesthetic
• Temporary or permanent numbness or tingling of the lip, chin, tongue or other areas
• Post treatment bleeding
• Post treatment infection
• Post treatment tissue swelling
• Root fragments may break; they may be left in the jaw
• Sinus involvement when upper teeth are removed, which may require additional treatment jaw
or alveolar bone may fracture during tooth removal, which may require additional treatment
• Healing may be delayed and require treatment such as for a dry socket
• Sensitivity, pain
• Damage to adjacent teeth restorations

I READ AND UNDERSTAND THE ABOVE INFORMATION AND THE INFORMATION GIVEN ME VERBALLY. BY MY SIGNATURE BELOW I CONSENT TO THE TREATMENT

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