Local Anesthesia Consent Form

This consent form is designed to make you aware of the risks involved with local anesthesia. The risks include, but are not limited to:

1. There are risks of anesthesia that may affect your body, such as dizziness, nausea, vomiting, accelerated heart rate, slow heart rate, or various types of an allergic reactions. Any or all of these may require additional medical management or hospitalization.

Some other risks/reactions may include the bruising of the affected area, or side of the face receiving treatment. This bruising will disappear as the days pass.

2. Restricted mouth opening during recovery, sometimes related to muscle soreness at the site of the injection requiring physical therapy.

3. Local anesthesia may cause prolonged numbness that in some patients may result in injury from biting or chewing an area (such as the lip, cheek or tongue) that has received local anesthesia.

4. Injury to nerves that can result in pain numbness, tingling or other sensory disturbances to the chin, lip cheek, gums, or tongue. This may persist for several weeks, months or rarely be permanent.

5. Local anesthesia is administered with a very small fine needle. In very rare instances these needles may break off and be lodged in the soft tissue.

PLEASE ASK THE DENTIST IF YOU HAVE ANY QUESTIONS REGARDING THIS CONSENT FORM.

I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT AND HAVE DISCUSSED ALL QUESTIONS OR CONCERNS THAT I MAY HAVE REGARDING LOCAL ANESTHESIA.

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