Ronak Patel, D.D.S.

355 E. Westchester Pkwy, Suite 200 Grand Prairie, TX 75052


Oral Surgery and Dental Extractions Consent

Patients Name:
Phone Number:
Email Address:

I UNDERSTAND that ORAL SURGERY and/or DENTAL EXTRACTIONS include possible inherent riskssuch as, but not limited to the following:

  1. Injury to the nerves of the lips, tongue, tissues in the floor of the mouth, and/or the cheeks, etc. These possible nerve injuries can cause numbness, tingling, burning, and loss of taste in the case of the tongue which may be of a temporary nature lasting a few days, a few weeks, a few months, or could possibly be permanent.
  2. Bleeding and/or bruising: Bleeding could last for several hours. Should it persist, particularly being severe in nature, it should receive attention and this office must be contacted. Bruising may possibly be prolonged.
  3. Dry socket occurs on occasion when teeth are extracted and is a result of a blood clot not forming properly during the healing process. Dry sockets can be extremely painful. Smoking, drinking liquids through a straw, and not following post-operative recommendations can increase the chances of this complication.
  4. Sinus involvement: In some cases, the root tips of upper teeth lie in close proximity to the tissues of the sinuses. During extraction or surgical procedures, the thin bone and tissues surrounding the sinus membrane may be perforated. Should this occur, it may be necessary to have the sinus surgically repaired.
  5. Infection: No matter how carefully surgical sterility is maintained, it is possible, because of the existing non-sterile or infected oral environment, for infections to occur postoperatively. At times these may become serious. Should severe swelling occur, particularly accompanied with fever or malaise, attention as soon as possible should be received, and this office must be contacted. In some cases, hospitalization and/or treatment with I.V. antibiotics may become necessary.
  6. Fractured jaw, roots or bone fragments: There is a possibility, even though extreme care is exercised, that the jawbone, teeth roots or bone spicules may be fractured which may require referral to a specialist for treatment. A decision may be made to leave a small piece of root or bone fragment in the jaw when its removal would require extensive surgery and/or risk of complications.
  7. Injury to adjacent teeth, fillings or porcelain crowns may occur no matter how carefully surgical and/or extraction procedures are performed. Fractured fillings or crowns may require replacement.
  8. Bacterial endocarditis: Because of the normal existence of bacteria in the oral cavity, the tissues of the heart in some cases and due to a number of conditions may be susceptible to bacterial infection transmitted from the mouth to the heart through the circulatory system. A condition called bacterial endocarditis (an infection of the heart) may occur which can result in damage to heart valves. If any heart problems are known or suspected (such as a heart murmur following rheumatic fever, existence of an artificial heart valve, cardiac damage following Phen-fen use, etc.), the dentist must be informed prior to surgery.
  9. Muscle or jaw soreness may be noticed following oral surgery and especially third molar extractions. Pre-existing conditions affecting the jaw joints (TMJ) may be aggravated by oral surgery. Clicking, popping, muscle soreness and difficulty opening may be noticed for some time following surgery. If such symptoms or conditions persist, the patient should call our office. The patient must notify the dentist of any such pre-existing conditions prior to surgery.
  10. Unusual reactions to medications given or prescribed: Reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. It is important to take all prescription drugs according to instructions. Women on oral contraceptives must be aware that antibiotics can render these contraceptives ineffective. Caution must be exercised to utilize other methods of contraception during the treatment period.
  11. Bisphosphonate Drug Risks: For patients who have taken drugs such as Fosamax, Actamel, Boniva or any other drug prescribed to decrease the resorption of bone as in osteoporosis, or for treatment of metastatic bone cancer, there is an increased risk of osteonecrosis or failure of bone to heal properly following any oral surgical procedure involving bone, including extractions.
  12. It is my responsibility to contact the dentist and seek attention should any circumstances occur postoperatively, and I shall diligently follow any preoperative and postoperative instructions given me.

*INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of surgical treatment and/or extraction of teeth and have received answers to my satisfaction. I have been given the option of seeking care with an oral and maxillofacial surgeon. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. Patel and/or his associates to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications.

Tooth Number:

Patient/Legal Guardians Signature:

Use your mouse cursor or the tip of your finger to sign below


Doctors Signature:

Use your mouse cursor or the tip of your finger to sign below


© 2024 - American Dental Software All rights reserved.