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# Informed Consent for Extraction Official Clinical Data Record Submission
Patient's Name: [Patient Name Response] |  | Date: [mm/dd/yyyy]
Diagnosis: [Diagnosis Response] |  | Treatment Area: [Teeth/Quadrants Response]
I understand that there may be alternatives to the extraction of teeth. After considering the various options, I have chosen an extraction. I understand that there are various normal complications that can occur despite all efforts to the contrary as a result of the extraction(s) which include but are not limited to:
Allergic reaction to medications or anesthetics used in the extraction process. Pain, swelling, infection, bruising, and bleeding. Stiffness of the adjoining or nearby muscles. Numbness – There is a possibility of injury to the nerves of the face or tissues of the oral cavity during the administration of anesthetics or during the extraction, which may cause a numbness of the lips, tongue, tissues of the mouth and/or facial tissue. This numbness is usually temporary but may be permanent. Fracture of the root of the tooth, which may also result in the root tips being left in place or displacement of the root tip into the sinuses and/or nearby. Dry sockets, aspiration and/or swallowing of foreign objects. Damage to adjacent teeth and/or restorations.
I further understand that this procedure can also be performed by a specialist and request that this treatment be performed at this office by a general dentist. No guarantee or assurance has been given to me by anyone that the proposed treatment will cure or improve the conditions listed above. I have read and understand the above and have had all my questions answered to my satisfaction and I give my consent to proceed with the recommended Extraction.
Patient/Guardian: [Digitally Endorsed by Patient] |  | Date: [mm/dd/yyyy]
Witness: [Digitally Endorsed by Witness] |  | Date: [mm/dd/yyyy]
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