Dr. Craig Consent To Treatment Form

Dr. Craig Consent To Treatment Form
Name *

First Name Last Name
Date *

Month Day Year
Date
1. I authorize upon Dr. David Craig the following procedure and treatment:or whoever he/she may designate to perform such treatment. I also consent to such additional or alternative procedures that may be found immediately necessary during the course to such procedures or treatment. *
2. The nature of and the purpose of the treatment, possible alternative methods of treatment, the risks involved and the possible complications have been explained to me by *
ALTERNATE TO SURGERY: Risks to my health if these teeth are not removed include, but are not limited to:
     1. Infection
     2. Cyst or tumour formation
     3. Periodontal (gum) Disease
     4. Increased risk for complications if removal is required at a later time.

POSSIBLE COMPLICATIONS which have been discussed with me include, but are not limited to:
     1. Injury to the nerves to the lower lip and tongue causing numbness, which could possibly be permanent.
     2. Bleeding and/or bruising which may be prolonged.
     3. Dry socket.
     4. Involvement of the sinus above the upper teeth.
     5. Infection.
    6. Decision to leave a small piece of root in the jaw when its removal would require extensive surgery and increased risk of complication.
     7. Injury to adjacent teeth or fillings.
     8. Fracture of the jaw.
     9. Trismus – Limited jaw opening.

3. I acknowledge that no guarantee or assurance has been made to me as to   the results that may be obtained.

4. I consent to the administration of such anesthetic as may be considered necessary or advisable by these dentists under whose care I hereby place myself.

5.   I AGREE to cooperate completely with Dr. Craig and will follow postoperative instructions to the best of my ability for my own comfort and safety. I have had the opportunity to ask questions concerning these procedures.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO TREATMENT AND THAT THE EXPLANATION THEREIN REFERRED TO WERE IN FACT MADE TO ME AND THAT THE FORM WAS FILLED IN PRIOR TO TREATMENT.
Signature of Patient *

Clear
Date *

Month Day Year
Date
Signature of Witness *

Clear
Date *

Month Day Year
Date
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