Patient's Name (required)
Today's date (required)
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.
I hereby authorize Dr. Bravo and staff to perform the following procedure:
and to administer the anesthesia I have chose, which is
Local anesthesiaLocal anesthesia with Oral PremedicationLocal anesthesia with Nitrous Oxide/Oxygen Analgesia
Other treatment options: All possible treatment options, including no treatment, have been discussed with me. The risk and benefits of all the options have been clarified and all of my questions have been answered. I have therefore made an informed decision regarding my treatment of choice.
I understand that there are known consequences of surgery and administration of drugs and anesthetics that include (but not limited to): pain and discomfort, swelling, bleeding, bruising, and infection. Changes in the bite or restricted mouth opening, secondary to stress on the jaw joint (TMJ) may occur. There is also the possibility of injury to adjacent teeth or other tissues of the face or mouth, bone/jaw fractures, delayed healing, dry socket, or unexpected drug reactions or allergies.
With tooth extraction, I understand that there may be unexpected damage to adjacent teeth or fillings, sharp ridges or bone splinters that may require later surgery to smooth or remove, dry socket, which will require additional care, or small fragments of tooth root, which may be left in place to avoid damage to vital structures such as nerves or sinus.
Lower tooth roots may be very close to the nerve and surgery may result in pain or a numb feeling of the chin, lip, cheek, gums, teeth and/or tongue (including possible loss of taste sensation) lasting for weeks, months, or may rarely be permanent. On upper teeth were roots are close to the sinus, a sinus infection may develop, a root tip may enter the sinus and/or opening from mouth to the sinus may occur which could later require medication or additional surgical procedures.
Anesthetic risks include: discomfort, swelling, bruising, infection, and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) that may cause prolonged discomfort and/or disability and may require special care. Nausea and vomiting, although uncommon, may be unfortunate side effects.
Your Obligations if nitrous oxide/oxygen analgesia or oral pre- medication is to be used. I've been given all these instructions verbally and on paper.
I understand that no guarantee can be promised, and I give my free voluntary consent for treatment. I realize that my doctor may discover conditions requiring additional and/or different surgical procedures from that which was planned, and I give my permission for those additional procedures that are advisable in the exercises of professional judgment.
Information for female patients
I have informed my doctor about my use of birth control pills. I have been advised that certain antibiotics and other medications may neutralize that preventive effect of birth control pills, allowing for conception and pregnancy. I agree to consult with my personal physician to initiate additional forms of birth control during the period of my treatment, and to continue those methods until advised by my personal physician that I can return to the use of oral birth control pills.
My signature bellow signifies that all questions have being answered to my satisfaction regarding this consent and I fully understand the risks involved of the proposed surgery and anesthesia. I certify that I speak, read and write English.
Patient's (or legal Guardian's) signature
I accept the submission of this form and information in electronic format Yes