The Healthy Mouth

 Richard A. Miller DDS,FAGD

A Preventive Dental Practice

Extraction Consent Form Dr. Miller will be removing the following teeth: ___________________
​ For the following reason(s):  ___Abscess      ___ Periodontal disease     ___ Nonrestorability     ___ Other:
The consequences of not performing necessary extractions may include:·        -Continuation, growth, and/or spread of infection        -Pain and swelling        -Systemic infection, such as fever, sepsis, and (in rare cases) death·        -Aspiration (inhaling) of loose teeth or tooth fragments  Though rare, the following complications may occur during or after dental extractions: -Pain and swelling -Injury to neighboring teeth, restorations, or soft tissues -Reversible or irreversible nerve damage -Dry socket (a painful, noninfectious complication) -Infection -Adverse reactions to medications, anesthesia, or substances used for the extraction -Retained fragments of teeth in the jaw (if the risk of removal outweighs the benefit) -Perforation of the maxillary sinus, possibly requiring further treatment -In rare cases, fracture of the jaw requiring further treatment  I understand that tooth extraction is an elective procedure, and there are often alternative treatments, such as a root canal and restoration or performing no treatment at all.  My dentist has described other options, invited me to ask questions, and I am electing to proceed with the extraction.
I will follow the verbal and written postoperative instructions and return for a follow-up appointment if requested. __________________________________                                                   ____________
Patient or Guardian Name                                                                   Date  __________________________________                                                    ____________ Witness                        Date