Extraction Consent
Name
*
First Name
Last Name
Patient Information and Consent Form for Tooth/Teeth Extraction #
Local Anesthesia:
*
By receiving local anesthetic, there is a possibility of temporary or permanent numbness of the lip, tongue, chin, cheek, as well as, thrombophlebitis (inflammation of the vein), temporary TMJ problems, and possible allergic reaction.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of their surroundings and able to respond rationally to questionsand directions. I understand I am able to drive myself to and from my appointment.
Patient Name
*
First Name
Last Name
Patient/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Witness
Witness Name
Submit
Should be Empty: