At Cambridge Dental, 39 Newnham Road, CB3 9EY Cambridge
This consent form is designed to demonstrate your informed consent to the removal of a permanent tooth or teeth as part of your treatment plan.
For the extraction of a tooth there is some standard information that you should be aware of in advance, before consenting to go ahead with the procedure.
Extraction is an irreversible procedure.
The advantages of having the tooth removed can include prevention of further infection, pain, decay or crowding.
The risks of having a tooth removed will include some tenderness and swelling for a few days, and possible prolonged healing.
Occasionally an extraction may involve some minor surgery to the surrounding gum, removal of the tooth in more than one piece and removal of small amounts of surrounding bone: one or more stitches may be placed, which may need removal at a follow up appointment. The area will stay numb for several hours after treatment. There is minor risk of damage to adjacent or opposing teeth or restorations.
The risks have been assessed from clinical examination and X-rays, and discussed with you.
For extractions the procedure is generally carried out by the dentist on our team who has specialist interest in surgical procedures. If the procedure is straightforward you have the option of selecting treatment with the dentist of your choice and there is also the option of referral to a specialist oral surgeon for treatment. You will have been informed if such a referral is clinically necessary.
There is of course the option of not having the extraction as long as you are aware of the problems that may develop from not having this tooth removed.
After any extraction there will be a gap in this area: it has been discussed the options for this gap, including leaving it as it is or the possible ways of having something to replace the tooth.
By signing this document you acknowledge that you have had the objectives, options, benefits, risks and long term consequences explained to your satisfaction. The specific procedures involved have been described and you are aware of both alternative treatments and the option of not undertaking treatment.
Treatment has been planned in the expectation that it will be successful but requires your co-operation and involvement and it cannot be guaranteed to succeed in every individual case.
I am happy that I have all the information I need to make a decision about having tooth removals, and feel that my questions have been answered.
I understand that the quoted fees are an estimate and are due on completion of each stage of treatment.