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Inwood Dental PC
Implant + Braces Center

Consent forms




Oral surgery (extraction)

I fully understand this consent for surgery and the reasons why the recommended treatment is necessary.  I have been given the opportunity to ask questions regarding the recommended treatment and have been given satisfactory answers.  I understand that no guarantee regarding the treatment has been made or implied.

TREATMENT: __________________________________________________________ _______________________________________________________________________

B. TREATMENT ALTERNATIVES I elected the treatment listed above even though the following alternatives have been explained to me as being both practical and possible.

TREATMENT ALTERNATIVES: ___________________________________________ ________________________________________________________________________

C. ANESTHESIA/MEDICATIONS I also authorize the recommended treatment to be performed with the following anesthetics and/or medications: _____ Local anesthesia only _____ Local anesthesia with nitrous oxide and oxygen

D. RISKS AND CONSEQUENCES I understand that there are risks associated with the administration of medications and performance of the recommended surgery such as the items check below:

_____ Drug reactions and side effects

_____ Post-operative bleeding and pain

_____ Necessary removal of bone during tooth extraction

_____ Post-operative infection or bone inflammation

_____ Possible damage to the sinus when upper back teeth are removed which may require surgical repair at a future date

_____ Possible nerve damage when lower wisdom teeth are removed which can result in either temporary or permanent tingling or numbness in the lower lip

_____ Fracture of the mandible

_____ Jaw joint (TMJ) pain, malfunction and/or difficulty in opening mouth due to muscle spasms, following removal of lower teeth