CONSENT FOR SURGICAL & WISDOM TOOTH EXTRACTION


I authorize the Dentists at West Grande Prairie Dental to perform Extractions on tooth/teeth:*

If unforeseen conditions arise during the operation, calling for the doctor’s judgement for procedures in addition to, or different from those now contemplated, I further request and authorize the doctor to do whatever he deems advisable.

I have been informed of other possible alternative and/or supplemental methods of treatment. Post-operative risks of the proposed surgery include, but are not limited to;

  • Post operative discomfort
  • Restricted mouth opening for day, weeks or longer
  • Paresthesia (numbness) of the jaw or gums which could persist for weeks, months or in rare cases be permanent
  • Clicking in jaw
  • Swelling or Bruising
  • Soreness or pain in the temporomandibular joints (jaw joints)
  • Dry socket (blood clot dislodging), which may require frequent post operative care
  • For upper extractions) risk of perforation into the sinus cavity

I further understand that if no treatment is rendered, my present condition will likely worsen in time.

No guarantee, warranty or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. It is the doctor’s opinion that this treatment will be helpful and that any further loss of supporting tissues or bone would occur sooner without the recommended treatment.

I understand that long term success requires my continued performance of removing plaque (brushing and flossing) and my commitment to regular cleanings with the dental hygienist and regular recall visits with the dentist.


I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH; IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.