Informed Consent for Tooth Extraction and Related Surgery

Informed Consent for Tooth Extraction and Related Surgery



1. My dentist has recommended the following extraction surgery.

2. I have been informed of the risks and complications including (not limited to) : adverse reactions to anesthesia, bleeding, pain, swelling, dry socket, sinus perforation for upper teeth extractions, damage to the adjacent tooth or restorations, temporary or permanent numbness or tingling of the lip, chin, tongue or other areas, jaw or alveolar bone fractures.

3. I am aware that the practice of dentistry and dental surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the success of this procedure. I am further aware that there is a risk of failure or further corrective surgery may be necessary. Such failure and remedial procedures may involve additional fees to be assessed.

4. I agree to cooperate with the post-operative instructions of my dentist, realizing that any deviation from the instructions or lack of cooperation could result in a less than optimum result

5. To my knowledge, I have given an accurate report of my health history. I have also reported any prior allergic or unusual reactions to drugs, food, anesthetics, and any prior adverse reactions to medical and dental treatments.

6. I certify that I have read and fully understand the above authorization and informed consent to the procedure and that all of my questions, if any, have been answered. I have had the opportunity to review it before signing it.

Patient or Guardian Signature


Dentist Signature

Kwan M. Lee DDS

Witness Signature

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