Notice: Trying to get property 'fields' of non-object in /home/elkd91/public_html/wp-content/plugins/wp-forms-signature-contract-add-on/admin/includes/esig-wpform-settings.php on line 249

Warning: array_key_exists() expects parameter 2 to be array, null given in /home/elkd91/public_html/wp-content/plugins/wp-forms-signature-contract-add-on/admin/includes/esig-wpform-settings.php on line 254

Notice: Trying to get property 'fields' of non-object in /home/elkd91/public_html/wp-content/plugins/wp-forms-signature-contract-add-on/admin/includes/esig-wpform-settings.php on line 249

Warning: array_key_exists() expects parameter 2 to be array, null given in /home/elkd91/public_html/wp-content/plugins/wp-forms-signature-contract-add-on/admin/includes/esig-wpform-settings.php on line 254

Informed Consent to Dental Surgery

Eltek Dental Center
Tel: (905)-770-5100

Patients Name   

Purpose of treatment

Extractions are considered for: orthodontic reasons, severely decayed teeth, infected teeth with severe periodontal disease and impacted teeth or for the prevention of future infection or problems. After removal of a tooth, an artificial bone graft may be placed into the socket to preserve the jawbone. I have been informed that ________ is a dental surgeon (general dentist).

Potential Complications

The following is not a list of all the potential complications but it does cover the most common ones.

Pain: Varies individually and can be controlled with medication

Bruising, swelling and difficulty opening: Generally, resolve within one week

Bleeding: A small amount of bleeding is not unusual for a day and should stop by applying firm pressure with gauze. More than this is unusual and requires attention by the surgeon.

Infection: The chances of post op infection increases with smoking and poor oral hygiene. Should infection develop, it may be require additional oral antibiotics or iv in a hospital setting, dressing the wound, or sometimes an incision and draining. Signs and symptoms of infection include severe pain, non-resolving swelling, foul odor, fever and chills.

Numbness: Surgery in the jaw is often close to the nerves and there is no test that can accurately predict where nerves lie in the gum or bone. Damage to the nerve can result in temporary or permanent changes in the sensation of the affected area. This includes numbness, tingling, painful sensations or a loss of taste sensation. While occurrences of such changes in the sensation are uncommon, very little can be done if they occur.

Fractures: Broken jawbones are a rare complication. The risk does rise with older patients and when the bone is severely resorbed. Should a fracture occur, wiring of the jaw or wearing of a splint or denture may be necessary.

Remaining Roots and sharp bony edges: Small pieces of the tooth root may remain in the jaw if it is decided that its removal would complicate the surgical outcome. Another surgery may be required to smooth the edges.

Sinus Problems: Surgery in the upper jaw may be complicated by the position of the sinus. Should a tooth or root be lodged in the sinus, future surgical procedures may be required to remove it. Opening of the sinus is also possible and may require medication or surgery to repair it.

Damage to Adjacent Teeth: Sometimes, an adjacent tooth or its supporting structures may be damaged. The chances of this are increased if the adjacent tooth is weak with a large filling or crown. Subsequent problems may necessitate either root canal or extraction of the affected tooth.

Rejection of the bone graft: A biocompatible synthetic material is utilized for the bone grafting process. There have not been any reported rejections of the material utilized. If a rejection does occur then a second surgical procedure will be needed to remove the graft.


Consent: I have read the above the information and the dentist has explained the points that are pertinent to my case and been given alternatives. I understand this information and that there is no guarantee given that the proposed treatment will be successful in correcting the condition. Prior to the surgery, I may not be experiencing any pain or problems and realize there is a risk of failure, relapse, selective re treatment or worsening of the present condition despite care provided. My questions have been addressed.

Tooth/Teeth to be Extracted and Grafted  

Date January 21, 2021


Leave this empty:

Signed by Eltek Dental
Signed On: September 11, 2020

Signature Certificate
Document name: Informed Consent to Dental Surgery
Unique Document ID: 94b193ee919b1330321367c67f173aea67f742fb
Timestamp Audit
September 11, 2020 5:52 pm ESTInformed Consent to Dental Surgery Uploaded by Xayal Xudiyev - IP