This form obtains the patient's consent to perform general dental treatments and oral surgery procedures including but not limited to use of local anesthesia, radiographs, diagnostics aids, examinations, oral prophylaxes, fluoride applications, sealants, restorations, periodontal treatments, endodontic procedures, and extractions.
Informed Consent to Perform Surgery
I hereby authorize and direct the dentists of [[PRACTICE NAME]] to perform the following dental treatment(s) and/or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs, and/or other diagnostic aids. These treatments and/or procedures include, but are not limited to examinations, oral prophylaxes (cleanings), fluoride applications, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) procedures, and extractions.
I understand that there are risks involved in these treatments and hereby acknowledge that the risks have been explained to me, that I have had an opportunity to ask questions regarding the treatments and their risks, and that I fully understand those risks.
I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia, depending on the judgment of the doctors.
The treatment I am receiving today has been explained to me. Alternate methods of treatment, if any, have also been explained to me, as have the advantages, disadvantages, and risks of each. I am advised that, though good results are expected, the possibility and nature of complications cannot be accurately anticipated.
I recognize that during the course of treatment, unforeseen circumstances may necessitate additional or different procedures from those discussed. I, therefore, authorize and request the performance of any additional procedures that are deemed necessary or desirable.
I understand and have been informed that there are possible risks and complications associated with the administration of local anesthesia, sedation, and drugs. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa.
[x] I consent to the treatment(s) as described above.
Please Sign Here (Patient)
[x] I attest that I have discussed the risks, benefits, consequences, and alternatives to this/these treatment(s) with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained.
Please Sign Here (Dentist)
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