, Wisdom Teeth Removal Informed Consent

Medway Smile – Consent Form

    Wisdom Teeth Removal Informed Consent

    Informed Consent For Composite Cosmetic Bonding

    Wisdom teeth are the last teeth to erupt and are therefore most liable to be prevented from doing so in a crowded mouth. Those which are deeply impacted and asymptomatic are best left alone. Decisions about surgery vary widely. These teeth can cause problems such as pain, swelling and foul taste.

    I have been informed and understand the purpose and the nature of the wisdom tooth extraction procedure. I understand what is necessary. My Dentist has carefully examined my mouth and taken a history of my symptoms and examined my mouth and neck to check for signs of infection. Alternatives, if any, to this treatment have been explained.


    Pain, Swelling and/or Trismus (the inability to fully open the mouth) Nerve damage – loss of sensation to the lip and tongue
    • Subsequent stitches or infection in the extraction area
    • Potential complications and risks of anesthesia such as stroke and heart attack
    • A painful infection felt in the extraction area referred to as ‘dry socket’, characterised by bad smell and grey necrotic tissue inside the socket area. This is not uncommon post operatively in lower jaw extractions. If this occurs, make an appointment with your dentist immediately
    • Lingual nerve damage which can lead to loss of taste, permanent numbness, other tongue and mouth problems. Long-lasting loss of feeling in the cheek, tongue or lip that does not go away, ranging from total numbness to feeling of being pinched with pins and needles
    • Damage to structures of adjacent teeth or existing dental work
    • Fracture in the jaw can emerge if the surgeon must remove a portion of the bone in order to easily access the impacted tooth
    • Root fragments or bone splinters may be left behind in the gum tissue

    I agree to Sedation or Local Anaesthetic as discussed with the doctor. I agree not to operate a motor vehicle or hazardous device for at least 24 hours (in case I have received sedation) or more until recovered from the effects of the anaesthesia or drugs given for my care.

    To my knowledge I have given an accurate report of my physical and mental history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anaesthetics, pollen, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other condition related to my health.

    As with all surgical procedures, there are potential risks linked with extracting wisdom teeth. These comprise of issues like delayed healing or infection, both of which are possible to occur especially when the patient smokes or consumes alcohol at the time of recovery, or is in poor overall health and/or has a compromised immune system.

    I consent to photograph, filming, recording and X-rays of the procedure to be performed for the advancement of dental surgery, provided that my identity is not revealed.

    I consent to wisdom tooth removal surgery. I fully understand that during and following the contemplated procedure, surgery or treatment, conditions may become apparent which warrant in the judgement of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modification in design, materials or care, if it is felt this is for my best

    You may need a review appointment to check on you and remove any stitches. An appointment can be made for you. It is imperative that you follow the aftercare protocol which you will sign and consent to follow to promote optimal recovery following the procedure.


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