#101, 1829 Ranchlands Blvd N.W. Calgary, AB T3G 2A7 Ph: 403-241-1900 Fax: 403-241-8895
TOOTH EXTRACTION INFORMATION SHEET
I understand that there are potential risks in any treatment plan or procedure, and that in this specific instance such operative risks may include, but are not limited to the following:
Post-operative bleeding and swelling and soreness of the jaw Dry socket or delayed healing Infection and possible need for antibiotics or pain medication Injury to neighboring teeth, fillings or crowns Sinus Injury Jaw Injury Mandibular Nerve Injury: Tingling or numbness of surrounding skin and tissues. The duration of such numbness is in most cases temporary, but in rare instances it can be permanent. Loss of tooth or tooth fragments into surrounding tissues or spaces Decision to leave small piece of root in the bone when its removal would increase the risk of complications Any of these complications may require referral to an Oral Surgeon's office Increased chewing forces and potential shifting of neighboring teeth
Other treatment options (including no treatment) and their consequences have been explained to me.
I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness.
I understand the above and agree to undergo the procedure.