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Service Consent

    Dear Dr. Pollak DMD PC,

    I, , hereby grant consent for the dental extraction procedure recommended by you. I have been fully informed about the nature of the procedure, its purpose, and the potential risks associated with it. I understand that the extraction is being performed to address my dental condition, and I am aware of the common risks involved.

    Common Risks of Dental Extraction:

    1. Pain and Discomfort: It is possible to experience pain and discomfort during and after the extraction procedure, which may require appropriate pain management.

    2. Swelling and Bruising: Swelling and bruising around the extraction site may occur, and while it is usually temporary, it can persist for a few days.

    3. Bleeding: There may be bleeding during and after the extraction, and while measures will be taken to control it, I understand that some bleeding is normal.

    4. Infection: There is a risk of infection at the extraction site, which may require additional treatment, including antibiotics.

    5. Nerve Injury: There is a small risk of temporary or permanent nerve injury, which could result in numbness, tingling, or altered sensation in the surrounding areas.

    6. Damage to Adjacent Teeth: There is a slight risk of damage to nearby teeth, dental restorations, or existing dental work during the extraction process.

    7. Dry Socket: A dry socket may occur, leading to increased pain and delayed healing. Following post-operative care instructions is essential to minimize this risk.

    8. Incomplete Extraction: In some cases, it may not be possible to remove the tooth entirely during the initial procedure, necessitating additional treatment.

    I have had the opportunity to discuss the procedure, its risks, and potential alternatives with you. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand that while rare, unforeseen complications may arise during or after the extraction.

    Patient Address:

    City:

    State:

    Zip Code:

    Phone Number:

    Email Address:

    By signing below, I acknowledge that I have read, understood, and discussed the information provided above, and I willingly consent to undergo the dental extraction
    procedure.

    Your Signature

    Date:

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