Discussion and Consent for Extraction Form

Extraction involves the complete removal of a tooth from the mouth. Some extractions may require cutting into the gums and removing supporting bone and/or cutting the tooth into sections prior to removal.The intended benefit of extraction is to relieve my current symptoms and/or to permit me to continue with any additional treatment needed.

Risks of extraction: Pain, discomfort, bleeding, swelling, bruising, and stiff jaws may last several days. Infection may occur and require antibiotics and/or other procedures to treat the infection may be needed. Less common complications include: dry socket, loss or loosening of dental restorations, loss or injury to adjacent teeth and soft tissues, jaw fracture, sinus exposure (upper teeth), swallowing or aspiration of teeth and restorations. Small root fragments may break off from the tooth being extracted. Depending on their size and position they may either be left to remain in the jaw or may require additional surgery for removal. Nerve damage or disturbances that are temporary or permanent, such as numbness, itching, burning, or tingling of the lip, tongue, chin, teeth, or mouth tissues. Local anesthetic will be given. In rare instances patients have had an allergic or adverse medication reaction to anesthetic or temporary or permanent injury to the nerves and/or blood vessels from the injection. The injection area(s) may be uncomfortable following treatment, and my jaw may be stiff and sore from holding my mouth open during treatment. I understand that extracting the tooth may not relieve my symptoms and that complications may occur. Other treatment or procedures may be necessary.

I have provided as accurate and complete a medical and personal history as possible. I will follow any and all treatment and post-treatment instructions as explained and will permit the recommended diagnostic procedures, including x-rays. I realize that in spite of the possible complications and risks, my recommended extraction is necessary. I acknowledge that no guarantees, warranties, or representations have been made to me concerning the results of the operation or procedure.

I have discussed my treatment with Dr. McMullin and have asked and had my questions fully answered. I wish to proceed with the recommended treatment. I understand that I may also choose to have this procedure performed by an oral surgeon, but would prefer to have it performed by Dr. McMullin. I understand that if any unexpected difficulties occur, I may be referred to an oral surgeon for further care.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.