I understand that the extraction of a tooth (teeth) has been recommended by my dentist. 

I have had any alternative treatment (if any) explained to me, as well as the consequences
of doing nothing about my dental conditions. I understand that non-treatment may result
in, but not be limited to infection, swelling, pain, periodontal disease, malocclusion
(damage to the way the teeth hit together) and systemic disease/infection.
I understand that there are risks associated with any dental, surgical, and anaesthetic
procedure.

These include, but are not limited to:
1. Post-operative infection or inflammation
2. Swelling, bruising, and pain
3. Damage to adjacent teeth or fillings
4. Drug reactions and side effects
5. Bleeding requiring more treatment
6. Possibility of a small fragment of root or bone being left in the jaw intentionally
when its removal is not appropriate (such fragments may work their way partially
out of the tissue and need to be removed later)
7.Delayed healing (dry socket) necessitating several post-operative visits
8.Damage to sinuses requiring additional treatment or surgical repair at a later date
9.Fracture or dislocation of the jaw

10.  Damage to the nerves during tooth removal resulting in temporary, or possibly
partial or permanent numbness or tingling of the lip, chin, tongue, or other areas.

INFORMED CONSENT

I have been given the opportunity to ask any questions regarding the nature and purpose of tooth extraction and have received answers to my satisfaction. 

I voluntarily accept any and all risks,
including those listed above and including the risk of substantial harm, if any, which may be associated
with any phase of this treatment, in hopes of obtaining the desired results, which may or may not be
achieved. 

I am freely giving my consent to allow and authorise
my dentist to render any treatment necessary and/or advisable to my dental conditions, including the prescribing and
administering of any medications and/or anaesthetics, deemed necessary to my treatment.