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Consent for Extractions

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Consent for Extractions( * mandatory to fill )

I understand that there may be alternatives to the extraction of teeth. After considering the various options, I have chosen 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, bleeding.

* Stiffness to the adjoining or nearby muscles.

* Numbness - There is the 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 tissues. This numbness is usually temporary but may be permanent.

* Fracture of the root tips, which may also result in the root tips being left in place or displacement of the root tip into the sinuses and/or place 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 in this office by a general dentist

* The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I may ask the attending dentist for a more complete explanation.

* This is my consent for the extraction, anesthetics, and x-rays to be taken.

* I have read and understand the above and have had all my questions answered to my satisfaction and I agree to proceed with the recommended extraction(s).

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