I authorize Jeffrey S. Tatarin, DDS to perform the following dental/surgical procedure(s):
EXTRACTION OF TEETH
1. The purpose and nature of the dental/surgical procedure have been fully explained to me. I have been fully informed of, and understand all of, the risks that are involved in the treatment to be rendered. I understand that there is a possibility of complications during and/or after the treatment which may include, but are not limited to, the following:
A. Post-operative bleeding, pain, swelling, bruising and/or soreness in the jaw. Pain, swelling and bruising may occur for several days after surgery. Recuperation may require several days at home.
B. Dry socket (delayed healing of the socket), infection and/or poor healing of the bone (bony spicule).
C. Damage and/or sensitivity to adjacent teeth or restorations.
D. The usual risks of local anesthetic injections. Although rare, this could include numbness, swelling, pain,
infection and abnormal or allergic reactions.
E. Involvement of the nerve within the lower jaw during the removal of lower molars resulting in temporary (but possible permanent) tingling or numbness of the lower lip, chin or tongue.
F. Temporomandibular joint dysfunction (TMD) which would cause pain and will limit jaw movements.
G. Slender or curved roots may break which could require removal, or may be left in place when the risk of removal outweighs the benefit.
H. Involvement of the sinus during removal of upper molars which may require additional surgical repair at a
later date.
I. Fracture of the jaw bone may occur.
Any complications will be treated here or you will be referred to the appropriate specialist if additional treatment is
needed. Treatment may consist of physical therapy, antibiotics or other drugs, or additional surgery.
2. Following the extraction(s), Dr. Tatarin will be using state-of-the-art techniques to clean and disinfect the
socket. These procedures provide the following advantages:
A. Removes diseased and infected tissue within and around the socket
B. Reduces post-operative pain which promotes quicker healing
C. Removes diseased bone
D. Promotes increased blood flow to the bone which improves clotting and healing
E. Reduces the incidence of dry socket, infection and/or poor healing of the bone (bony spicule)
F. Removes the periodontal ligament which reduces the incidence of cavitation formation I have been informed that these procedures are an out-of-pocket fee that is not covered by my insurance plan.
By initialing, I agree to have Dr. Tatarin perform these procedures.
3. Pain medications, oral sedation and/or IV sedation may also be administered. In this case, I understand that I am not to operate a motor vehicle or hazardous devices for a 24-hour period following surgery. Medication for pain, sleep or sedation may cause drowsiness; therefore, alcohol should be avoided when such medications are taken.
4. I understand that excessive smoking, alcohol or blood sugar may affect gum and bone healing. I agree to follow Dr. Tatarin’s home care instructions.
I agree to report to Dr. Tatarin for regular post-surgical examinations as
instructed.
5. Dr. Tatarin has recommended vitamin supplementations beginning at least 2 weeks prior to your
appointment and to continue at least 6-8 weeks after to increase bone healing.
– Vitamin D- up to 2000IU/day
– Vitamin C- at least 2000mg/day
– Vitamin K- at least the Recommended Daily Allowance
6. I am now giving my free and voluntary informed consent for the treatment named above. I am aware that the practice of dentistry is not an exact science, which the very nature of the treatment and my uniqueness as an individual require that no predictions can be made. I acknowledge that no guarantees have been made to me. I have had ample opportunity to ask any questions I might have and have had them answered to my satisfaction. I agree to abide by the doctor’s post-operative instructions and that my failure to properly care for my oral health may lead to further complications.
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