Healthcare Extraction Consent Form

Healthcare Extraction Consent Form

Provider/Practice Name:

Date of Examination:

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Please indicate if you have any of the following conditions:

Heart disease or recent heart surgery    Diabetes    Bleeding disorder / abnormal bleeding    Pacemaker or implantable device

Pregnancy or trying to become pregnant    Immunosuppressed / on steroids    Respiratory conditions (e.g., asthma, COPD)    Other

Procedure Description

Procedure to be performed: Extraction of tooth/teeth:

Reason for extraction:

Planned anesthesia / analgesia (select all applicable):
Local anesthesia (injection)    Nitrous oxide (laughing gas)    IV sedation    General anesthesia

Risks, Complications and Alternatives

I understand that the extraction procedure and associated anesthesia carry risks that may include, but are not limited to: persistent pain, swelling, infection, prolonged bleeding, dry socket (alveolar osteitis), fracture of the jaw or tooth roots, injury to adjacent teeth or restorations, temporary or permanent nerve injury causing altered sensation, sinus communication when extracting upper teeth, allergic reaction to drugs or anesthetics, need for further surgical intervention or hospitalization, and failure to resolve my condition. I acknowledge that no guarantee or assurance has been made concerning the results.

Alternatives to extraction that were explained to me include: retention with endodontic therapy, restorative treatment, monitoring, or referral for surgical consultation. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

I acknowledge I have been informed of the risks and alternatives and have had the opportunity to ask questions.

Consent for Treatment, Medications and Additional Procedures

I hereby authorize the Provider and such assistants as may be selected to perform the extraction described above, and to administer local anesthesia and other medications as deemed necessary. I authorize the administration of prescribed analgesics, antibiotics, and other medications in connection with the procedure.

I authorize the provider to perform such additional procedures as are necessary or advisable in the event unforeseen conditions are encountered during the procedure (for example, removal of fractured root fragments, suturing, or referral). I understand that such additional procedures may incur additional charges.

I consent to the proposed extraction, associated anesthesia, medications and any additional procedures as necessary.

HIPAA Privacy and Release for Insurance Claims

I authorize the release of my protected health information, including clinical findings and radiographs, to my insurance carrier(s) and other entities as needed for treatment, payment and healthcare operations. I further authorize payment of benefits directly to the provider for services rendered.

I authorize release of information for insurance claims and billing as described above.

Acknowledgment and Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand the nature of the proposed procedure, the risks involved, the available alternatives, and the expected benefits. I have had the opportunity to discuss this care with the provider and all questions have been answered in language I understand. I understand I may withdraw my consent at any time prior to the procedure.

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