Siraj R. Baig, DDS, PC & Associates

 

Oral & Maxillofacial Surgery

 

Date: 04-23-2024
Patient Name:
Procedure: Removal of Tooth #

Alternative to Surgery: I understand that if tooth/teeth are not removed, my condition may worsen resulting in complications including, but not limited to the following:

1. Infection
2. Cyst or tumor formation
3. Pain
4. Periodontal (gum) disease
5. Loss of additional teeth
6. Increased risk of complication if removal is required at a later time

Possible Complications from extraction that have been explained to me include but are not limited to the following:

1. Dry Socket and/or post-operate infection.
2. Injury to the nerves of the lower lip, tongue and cheek causing numbness which may be permanent.
3. Bleeding, bruising, or swelling that may be prolonged.
4. Decision to leave a small piece of the root of the tooth in the jaw when its removed would require extensive surgery and increased risk of complication.
5. Injury to adjacent teeth or fillings
6. Involvement of the sinus above the upper teeth
7. Unusual reactions to the medication given or prescribed

I understand that perfect result cannot be guaranteed. If any unforseen conditions arise during the procedure, I request and authorize the doctor to do whatever he/she seems advisable to correct the condition.
I agree to cooperate fully with the doctor and will follow post-operative instructions to the best of my ability for my own comfort and safety.I have had the opportunity to ask questions concerning the procedure.


Patient or Representative Signature