Richard A. Miller DDS,FAGD
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