Third Molar Extraction Consent Form

Patient Information:

Name: ________________________________________

Date of Birth: ________________________________

Procedure: Third Molar Extraction (Wisdom Tooth Removal)

I, [patient's name], hereby consent to undergo the extraction of my third molars (wisdom teeth). I understand that this procedure involves the surgical removal of one or more third molars located at the back of the mouth.

Purpose of Procedure:

The purpose of third molar extraction is to address issues such as impaction, crowding, infection, cyst formation, or other complications associated with the eruption of wisdom teeth.

Procedure Description:

During the procedure, the oral surgeon or dentist will administer local anesthesia to numb the area around the tooth. In some cases, sedation may be used to help the patient relax during the procedure. The dentist will then make an incision in the gum tissue to access the tooth and may need to remove bone or section the tooth into smaller pieces for easier extraction. After the tooth is removed, the surgical site will be cleaned and sutured if necessary.

Risks and Complications:

While rare, complications may occur during or after the procedure, including but not limited to:

• Bleeding
• Infection
• Dry socket (loss of blood clot)
• Nerve injury leading to temporary or permanent numbness or altered sensation in the lips, tongue, or cheeks
• Sinus communication (for upper wisdom teeth)
• Damage to adjacent teeth or restorations
• Jaw stiffness or pain
• Delayed healing or wound breakdown

Alternatives:

Alternative treatment options may include observation, antibiotics for infection, or referral to a specialist for further evaluation or treatment.

Expected Outcome:

The expected outcome of third molar extraction is the resolution of symptoms associated with impacted or problematic wisdom teeth, improved oral health, and prevention of future complications.

Patient Responsibilities:

I understand that it is my responsibility to follow all pre-operative and post-operative instructions provided by my dentist or oral surgeon, including any dietary restrictions, medication guidelines, and oral hygiene practices.

Questions and Concerns:

I have had the opportunity to ask questions and discuss any concerns about the procedure, risks, and alternatives with my dentist or oral surgeon. I am satisfied with the information provided and consent to undergo third molar extraction.

Patient Signature: ____________________________ Date: ________________

Witness Signature: ____________________________ Date: ________________

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