Dear Dr. Pollak DMD PC,

1. I, , hereby authorize and request that Dr. Pollak and his assistants perform the following extractions on teeth/tooth number(s) .

2. I am aware that an extraction involves the surgical removal of the tooth structure and root system of that tooth and surrounding bone and tissue. The extraction will be done either surgically, by sectioning the tooth, or by a simple extraction, by elevating the tooth out of its socket. The instruments that will be used will depend upon the nature and extent of the extraction but typically instruments that my dentist uses include a handpiece, elevators, forceps, and rongeurs. After the tooth is extracted, I also understand that sutures may be utilized.

3. I am aware that there are possible risks and complications from the surgical extraction of teeth which include the following:

• (a) Pain, bleeding, and swelling.

• (b) Discoloration and bruising.

• (c) Infection (requiring additional procedures).

• (d) Numbness, altered sensation, tingling sensation to the lip, chin, cheeks, gums, teeth and tongue (which may be permanent).

• (e) Changes in bite, chewing, eating, and speaking.

• (f) MPD (jaw muscle pain) and TMJ (jaw joint pain and injury to the joints); dislocation of the jaw joint.

• (g) Dry socket; inadequate clot formation; prolonged healing; requiring medicated packing.

• (h) Allergic reaction and/or rashes.

• (i) Nausea and vomiting.

• (j) Sinus hole, sinus perforation, and/or sinus involvement necessitating further surgery.

• (k) Fractured jaw, requiring further treatment.

• (l) Fractured root tip and/or fractured root, formation of bony splinters.

• (m) Residual root/tooth structure being left behind requiring another procedure.

• (n) Phlebitis (inflammation of blood vessels).

• (o) Injury to and stiffening of the neck and facial muscles.

• (p) Lacerations, abrasions, scars, and retraction marks.

• (q) Referred pain and injury to the ear, neck, and head.

• (r) Injury to and loss of other teeth and fillings including those with fillings, crowns, and bridges and damage to surrounding bridges as well as restorations.

• (s) Injury to the gum tissues and surrounding bone in the jaw.

4. I understand that I will receive a local anesthetic and/or other medication. In rare instances patients have a reaction to the anesthetic, which may require emergency
medical attention, or find that it reduces their ability to control swallowing. This increases the chance of swallowing or aspirating foreign objects during treatment.
Depending on the anesthesia and medications administered, I may need a designated driver to take me home. Rarely, temporary or permanent nerve injury can result from an injection.

5. I understand that, should any of the complications above occur, that I may require further and other surgical procedures. Should Dr. Pollak encounter an emergency situation during the extraction of any of my teeth, I hereby authorize them to perform such surgical procedures as they deem necessary.

6. I know that Dr. Pollak does not guarantee the success of the treatment that they perform upon me

7. I know that there are alternatives to extraction, including the following: Leaving the tooth in, performing a root canal, and trying to restore the tooth with appropriate restorative procedures. The doctor has also explained to me the risks with respect to each and every one of these alternatives and I hereby reject those alternative treatments and request that they perform the extraction(s).

I hereby acknowledge that Dr. Pollak has explained to me both through my reading of this informed consent form and also that they have verbally explained to me in detail the surgery, risks involved, alternative treatments, and the risks attendant to those alternatives. I hereby authorize them to operate.