I hereby authorize Dr. Matthew Harmon to administer local anesthetic and remove the following teeth:

The consequences of not performing necessary extractions may include:

• Continuation, growth, and/or spread of infection
• Pain and swelling
• Systemic infection, such as fever, sepsis, and (in rare cases) death
• Aspiration (inhaling) of loose teeth or tooth fragments

Though rare, the following complications may occur during or after dental extractions:

• Pain and swelling
• Injury to neighboring teeth, restorations, or soft tissues
• Reversible or irreversible nerve damage
• Dry socket (a painful, noninfectious complication)
• Infection
• Adverse reactions to medications, anesthesia, or substances used for the extraction
• Retained fragments of teeth in the jaw (if the risk of removal outweighs the benefit)
• Perforation of the maxillary sinus, possibly requiring further treatment
• In rare cases, fracture of the jaw requiring further treatment

I understand that tooth extraction is an elective procedure, and there are often alternative treatments, such as a root canal and restoration, or performing no treatment at all. My dentist has described other options (including tooth replacement) invited me to ask questions, and I am electing to proceed with the extraction.

I will follow the verbal and written postoperative instructions and return for a follow-up appointment if requested.

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