Extraction Consent

Background Information for Patients Considering
Extraction(s) Treatment:

Before treatment is commenced I would like you to read the following important information. If after reading this information you have any questions in relation to any aspect of your treatment please ask.

It is important to note that removing teeth is a surgical procedure. As with any surgical procedure there are inherent risks and the potential for post operative complications to occur.

The following is a list of potential complications or post operative sequelae that may occur during the removal of a tooth or teeth.

Swelling may occur on the side of the face where the tooth/teeth where removed. This is not unusual and will usually resolve in a few days.

After surgery you may experience limited opening of you mouth due to stiffness in the jaw muscles

Numbness of the lip and /or tongue on the side of the mouth where the tooth/teeth where removed may occur. In the majority of cases this is a temporary condition that resolves within a few days. However in some cases this numbness may take longer to resolve, and in rare cases permanent numbness of the lip and /or tongue can occur.

The teeth next to the tooth/teeth removed may ache temporarily - this is not uncommon

The corners of your mouth may be stretched and may crack - it is important to keep them moist with a suitable lip balm.

Bruising may occur on the side of the face that the tooth/teeth where removed - this is not unusual and usually resolves in a couple of days.

You may notice a slight elevation in body temperature in the initial 24-48 hours after having surgery.

Sutures (stiches) may be used to close the wound. If so a subsequent visit 4-5 days later will be required to remove them

The roots of the upper molar teeth lie in close proximity to the sinuses. Removal of these teeth my result in a communication with the sinus which can significantly delay healing.

Sometimes referral to a specialist is required to resolve this situation.

Specialist referral is available for this procedure.

After having undergone extraction/s you will be provided with a list of post operative instructions. It is important that you follow these instructions closely to ensure prompt healing.

Finally if you should have any further queries please do not hesitate to ask.

Health Funds:

Any quotation includes the Australian Dental Associations scheduled item numbers and tooth identification if applicable. These numbers are recognised by the health funds. I answer to you for the services that I provide and the fees that I charge. That is your right and my responsibility. Your insurer answers to you for the rebates they give. That is your right and their responsibility. It is neither my responsibility nor my right to be involved in that relationship.

Consent for Treatment:
Extraction(s)

This is my consent to provide the dental treatment as indicated in this form:

I have read any provided ADA handout for this course of treatment.
I have received a written or verbal quotation and I am clear on the costs involved in this course of treatment.
I have given the practice a full, complete and up to date medical and medications history.
I am aware that a specialist referral is available for this procedure
I fully understand the entire document and the what the treatment entails including advantages, disadvantages, limitations, risks.
The treating dental practitioner has explained the known possible complications of and alternative treatments.
The treating dental practitioner has answered all of my questions to my full satisfaction.
I understand that the results of the treatment can not be guaranteed.
I give my permission and consent for the extraction(s) to be performed.

First Name

Last Name

Signature

Sign Here

Date / Time

    
 
 
        
   Anton Nicosia 
 25/11/2022
 
 
  Great dental team - friendly, helpful & explained everything to me.
  
 
       
   Christa Michaelis 
 11/07/2022
 
 
  I had a tooth fitted with a crown today, following removal of an old filling. This was the second crown i had done here within eight months, in between I had my teeth cleaned and a filling as well. I can't speak highly enough of all the team members I have met, -dentists, technicians and reception staff. Everybody is friendly and competent.  Procedures are carried out gently and painlessly, with a lot of consideration for patient comfort. A very impressive 3-D-printer-like piece of machinery (see picture) enables the team to manufacture crowns in-house which means you don't have to attend twice. Can't wait to go back - already booked my next appointment ! 😉
I highly recommend Encounter Bay Dental to anyone in need of dental work!
  
 
       
   Brian Thorpe 
 04/06/2022
 
 
  Very good experience. Had root canal work done on infected tooth. Was able to get in the day after I phoned for an appointment. Would have had to wait 2 weeks to get in to see local dentist. Dentist very professional and explained procedure being done. Will definitely change to this dentist for any future work.👍👍👍
  
 
       
   julie jordan 
 14/04/2022
 
 
  Was fitted in at short notice with a very troublesome tooth. I can’t speak more highly about every aspect of the care taken & attention given to a fairly complex situation. Top notch! Highly recommended & I’ll be back!
  
 
       
   Cindy Headon 
 13/12/2021
 
 
  Professional, compassionate an EXCELLENT Customer Service.
"It's a YES from Me" !!!
Thank you so very much Georgia and Cipi. With thanks so very much and Regards,
Cindy 😆😆😆
  
 
       
   Mork 
 25/10/2021
 
 
  I am a new client as we just moved in down the road and so very happy with the quality of the work and all the staff where wonderful. Cheers
  
 
       
   Ramsey June 
 02/10/2021
 
 
  Had a really good experience, no fuss got the job done, friendly dentist, would recommend
  
 
  
 
  
 
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