Informed Consent for Extractions (EXT) Please complete this Consent for Extractions form below. If you have any questions call us on (615) 915-6090. HiddenVersion historyv1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header and no captcha (change), 2020-06-04 v1.2 : DOB changed to date dropdowns (change) Patient name:(* required) First Last Patient date of birth:(* required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Consent for extraction(s)What is an extraction (EXT) and why is it necessary? An extraction (or removal) of a tooth may be necessary if the tooth is misaligned and causing trauma to another tooth, periodontally involved and loose due to irreversible bone loss, a fracture, or if there is extensive decay that prevents it from being saved with a filling, crown, or root canal therapy. An EXT may be simple, requiring the use of hand instruments to remove or surgical, requiring cutting or removing a part of the tissue or bone surrounding the tooth. Sutures may be placed with a wound dressing or medicament to ensure best healing. Will it hurt? Typically not. Patients will receive local anesthetic prior to EXT in order to numb the area and should not feel sharp pain during the procedure but may feel pressure. Sometimes, antibiotics will be given prior to treatment if infection prevents the tooth from being adequately numb. EXTs can be completed in conjunction with some sort of sedation treatment for maximum comfort. Patients can expect some soreness or discomfort due to inflammation for the first few days after the extraction, which can generally be alleviated with over-the-counter pain medications. How long does it take? Simple EXT can be completed quickly, while surgical EXT require additional steps to be completed. The amount of time is typically determined by the reason for removal, extent of decay, shape of tooth, past endodontic therapy. Will medications be required? The dentist may elect to prescribe antibiotics before or after EXT depending on one's medical history or extent of infection, but they are usually not required. After the procedure, the dentist will generally place a natural wound dressing with therapeutic and antimicrobial benefits to aid with healing and discomfort, eliminating the need for opioids. While pain or anti-inflammatory medications may be prescribed, alternating use of over-the-counter Ibuprofen 600 mg and extra strength 500 mg Tylenol can be used for effective pain relief with minimal side effects. Please alert your doctor of any allergic or adverse reactions to any medications or foods, as the dentist may need to customize the peri or post-operative regimen to fit your needs. Is smoking OK after extractions? NO. For the fastest healing and maximum relief, one should wait at least 7 days prior to smoking to avoid reinfection or dry socket formation. Benefits of treatment: Removal of a non-restorable tooth will prevent further spread of infection Removal of loose tooth prevents spread of periodontal disease Alleviates pain or discomfort Risks of treatment: Allergic reactions to medications or anesthetics used Soreness, temporary discomfort, swelling and bleeding for 1-2 days (please follow post-op care instructions) Fracture or breakage of the root or crown during due to brittleness, leading to incomplete removal Fracture or breakage of restorative work on adjacent teeth Temporary or permanent loss of feeling in teeth, lips, tongue and surrounding tissue (paresthesia) Fractured jaw or bone fragments around EXT site Recurring infection that may require further surgical intervention, including dry socket (prevented by cleaning site and avoiding tobacco) Temporomandibular joint dysfunction (TMD) may occur Sinus involvement possibly requiring additional treatment or surgery Alternative treatment: no treatment or SDF if no infection is present (to buy time) The doctor has explained that the purpose of EXT is to remove the infected tooth and/or stabilize the progression of periodontal disease. The treatment and anticipated results have been explained to me. I understand that while extractions are typically performed in one visit, the doctor has not guaranteed or warranted a perfect result, and complications can occur that cause me to return on a second visit for further surgical intervention. Should this occur, I understand that I must return to receive all necessary surgical treatment to remove remaining root tips or bone fragments, and failure to do so would be risking reinfection. All risks and benefits have been explained to me and I have had opportunity to ask questions. I understand that this is an elective procedure and that not receiving any treatment can lead to infection that can spread, which may lead to other potentially life-threatening complications. By signing this form, I am freely giving my consent to allow and authorize Michael D. Vaughan, D.D.S., PLC, to perform the necessary and affiliated procedures for EXT of tooth number(s) due to:(* required) SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Consent?(* required) Yes No E-mail address:(* required) Please sign(* required)Important: You consent to sign this document electronically. [printfriendly]
