Before you give your permission for the removal of teeth, removal of impacted teeth (those that are “buried” or beneath the gums) other dental treatment, or the administration of certain anesthetics, you should understand that there are certain associated risks.
This form and your discussion with your doctor are intended to help you make informed decisions about your surgery. As a member of the treatment team, you have been informed of your diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the procedure and , any associated costs.
It has been recommended that I have the following tooth (teeth) extracted by Dr. _____: The extraction is necessary because of: Pain Infection Periodontal (gum) disease Decay Broken Tooth/Teeth
TOOTH EXTRACTION CONSENT FORM Before you give your permission for the removal of teeth, removal of impacted teeth (those that are “buried” or beneath the gums), or other dental treatment, or the administration of certain anesthetics, you should understand that there are certain associated risks. 1. EXTRACTION.
Free Tooth Extraction (Removal) Consent Form | PDF | Word
2024年9月16日 · A tooth extraction consent form is filled out by dental patients to confirm their willingness to have one or more teeth pulled. Unlike general consent forms, this document contains medical details specifically related to tooth extractions, such as the teeth to be removed and the side effects patients typically experience during and after the ...
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18 Free Dental (Patient) Consent Forms [Word | PDF] - Word …
What is a Dental Consent Form? This is a written form that gives authorization, by the patient, to allow their dentist to proceed with treatment. It requires the signature of the patient, and it should be a comprehensive form that covers risks, benefits, alternatives, and medical issues.
PATIENT’S CONSENT FOR TOOTH EXTRACTION / RIDGE PRESERVATION Name: _____ Date: _____ Tooth: _____ EXPLANATION OF DIAGNOSIS: I have been informed of the need for a dental extraction (the removal of a tooth or several teeth). The reasons for this extraction could be irreparable tooth decay, cracked or
Dental Extraction Consent Form - TemplateRoller
The Consent Form for dental extraction usually mentions such dental conditions of non-treatment as infection, swelling, and pain. It can also include dental diseases, like periodontal disease, malocclusion, and systemic infection.
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If the baby tooth to be removed will not be replaced promptly by the permanent tooth orthodontic complications can result. This can include drifting of the adjacent and opposing teeth into the space, thereby leaving insufficient room for the permanent tooth to grow into. If the permanent tooth will not erupt promptly
Tooth Extraction Consent Form Regarding patient: _____ This is my consent for Dr. _____ to perform the following treatment which has been explained to me to be advisable or necessary: Extraction of tooth/teeth #_____. Alternatives to this treatment include: _____.