Wisdom Teeth Removal - Patient information and consent form

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Wisdom Teeth Removal - Patient information and consent form

  1. 1. U.R. No (Please place patient label here) Surname Given Names WISDOM TEETH REMOVAL D.O.B. Sex M F GPA. INTERPRETER/ CULTURAL NEEDS This nerve is very close to the area of surgery, with a slight risk of some damage to the nerve.An Interpreter Service is required yes no This may cause numbness of the lower teeth,If yes, is a qualified Interpreter present yes no lower lip and chin. This may be temporary (6 –A Cultural Support Person is required yes no 12 months) or permanent.If yes, is a Cultural Support Person present (d) Damage to the Lingual Nerve on each side of yes no the Mandible (lower jaw). This nerve passes very close to the tongue side of the lowerB. CONDITION AND PROCEDURE wisdom tooth and gives feeling and taste to thatThe dentist has explained that I have the following side of the tongue.condition: (Dentist to document in patient’s own This nerve is very close to the area of surgery, PROCEDURAL CONSENT FORMwords) with a slight risk of some damage to the nerve. This may cause numbness and loss of taste to PROCEDURAL CONSENT FORM that side of the tongue. This may be temporary (6 – 12 months) or permanent.The following dental treatment will be performed: (e) The wisdom tooth root tip may break off inRemoval of ………………………wisdom teeth. small pieces – less than 1mm - when the tooth(Oral surgeon/ dentist to document number of teeth is taken out.to be removed). The oral surgeon/ dentist may not removeThere will be some pain and swelling following a those pieces if there is a chance that the nervestooth extraction. This may require pain killers. or other structures may be damaged duringThere will also be bleeding of the socket. This is removal.usually minor and easily controlled by applying (f) Damage to teeth growing tightly against thepressure. wisdom teeth during removal of the wisdom teeth.C. ANAESTHETIC (g) Weakness of the jaw due to removal of theSee "About your anaesthetic" information sheet for wisdom teeth. The jaw may break during theinformation about the anaesthetic and the risks procedure or during the healing period.involved. If you have any concerns, talk these over (h) If the upper teeth are close to the sinuses,with your anaesthetist. removal may cause a hole between the mouthIf you have not been given an information sheet, and the sinus. This may need further surgery.please ask for one. E. SIGNIFICANT RISKS AND RELEVANTD. RISKS OF THIS PROCEDURE TREATMENT OPTIONSThere are some risks/ complications, which include: The dentist has explained any significant risks and(a) Infection of the extraction socket (dry socket). problems specific to me, and the likely outcomes if This may cause some pain and discomfort, but complications occur. is usually easily managed by the oral surgeon/ The dentist has also explained relevant treatment dentist. options as well as the risks of not having the(b) Biting of the numb lip which may cause damage procedure. after the teeth have been removed. You will be (Dentist to document in space provided. Continue in watched closely by your parent/ carer until the Medical Record if necessary. Cross out if not numbness wears off. applicable. )(c) Damage to the Inferior Dental Nerve on each side of the Mandible (lower jaw). This nerve passes very close to the root of the lower wisdom tooth (often in contact with it) and gives feeling to the lower teeth, lower lip and chin on that side.©Queensland Health: Dental_02 Version 5: 12/2005 Page 1 of 2
  2. 2. U.R. No (Please place patient label here) Surname Given Names WISDOM TEETH REMOVAL D.O.B. Sex M F GP Name of Patient/F. PATIENT CONSENT Substitute decision maker and relationshipI acknowledge that: SignatureThe dentist has explained my dental condition andthe proposed procedure. I understand the risks of Datethe procedure, including the risks that are specificto me, and the likely outcomes. Substitute Decision Maker Under the Powers of Attorney Act 1998 and/ or the Guardianship and Administration Act 2000. IfThe dentist has explained other relevant treatment the patient is an adult and unable to give consent, an authorisedoptions and their associated risks. The dentist has decision- maker must give consent on the patient’s behalf.explained my prognosis and the risks of not havingthe procedure. G. INTERPRETERS STATEMENTI have been given a Patient Information Sheet I have given a translation in ..……….….…………….on Anaesthesia (Version 2: 11/2002). (state the patient’s language here) of the consent form and any verbal and written information given to theI have been given a Patient Information Sheet patient/ parent or guardian/ substitute decision(Version 5: 12/2005) about the procedure and its maker by the dentist.risks.I was able to ask questions and raise concerns with Name of Interpreterthe dentist about my condition, the procedure andits risks, and my treatment options. My questions Signatureand concerns have been discussed and answeredto my satisfaction. DateI understand that other dental procedures may bedone if further dental disease is found during the H. DENTISTS STATEMENTprocedure, or to correct other problems in my I have explained:mouth. - the patient’s conditionI understand that the dental treatment may includea blood transfusion. - need for treatmentI understand that if teeth are removed during the - the procedure and the risksdental treatment, that these may be retained for - relevant treatment options and their riskstraining purposes and then disposed of sensitively. - likely consequences if those risks occurI understand that a dentist other than the examiningdentist may do the procedure. - the significant risks and problems specific to this patient.The dentist has explained to me that if immediatelife-threatening events happen during the I have given the patient/ substitute decision-makerprocedure, they will be treated accordingly. an opportunity to:I understand that photographs or video footage may - ask questions about any of the above mattersbe taken during my operation. These may then be - raise any other concernsused for teaching health professionals. You will notbe identified in any photo or video. which I have answered as fully as possible.I understand that no guarantee has been made that I am of the opinion that the patient/ substitutethe procedure will improve the condition, and may decision-maker understood the above information.make my condition worse.On the basis of the above statements, Name of DentistI REQUEST TO HAVE THE PROCEDURE. Signature Date©Queensland Health: Dental_02 Version 5: 12/2005 Page 2 of 2
  3. 3. CONSENT INFORMATION - PATIENT COPY WISDOM TEETH REMOVALPROCEDURE (g) Weakness of the jaw due to removal of the wisdom teeth. The jaw may break duringRemoval of wisdom teeth as listed on the the procedure or during the healing period.consent form. There will be some pain andswelling following a tooth extraction. This may (h) If the upper teeth are close to the sinuses,require painkillers. There will also be bleeding removal may cause a hole between theof the socket. This is usually minor and easily mouth and the sinus. This may need furthercontrolled by applying pressure. surgery.RISKS OF THIS PROCEDURE I ACKNOWLEDGE THAT:There are some risks/ complications, which The dentist has explained my dental conditioninclude: and the proposed procedure. I understand the(a) Infection of the extraction socket (dry risks of the procedure, including the risks that socket). This may cause some pain and are specific to me, and the likely outcomes. discomfort, but is usually easily managed The dentist has explained other relevant by the oral surgeon/ dentist. treatment options and their associated risks.(b) Biting of the numb lip which may cause The dentist has explained my prognosis and damage following removal of the teeth. You the risks of not having the procedure. need to be watched closely by the parent/ I have been given a Patient Information carer until the numbness wears off. Sheet on Anaesthesia (Version 2: 11/2002).(c) Damage to the Inferior Dental Nerve on I have been given a Patient Information each side of the Mandible (lower jaw). This Sheet (Version 5: 12/2005) about the nerve passes very close to the root of the procedure and its risks. lower wisdom tooth (often in contact with it) and gives feeling to the lower teeth, lower I was able to ask questions and raise concerns lip and chin on that side. This nerve is very with the dentist about my condition, the close to the area of surgery, with a slight procedure and its risks, and my treatment risk of some damage to the nerve. This options. These have been discussed and may cause numbness of the lower teeth, answered to my satisfaction. lower lip and chin. This may be temporary I understand that other dental procedures may (6 – 12 months) or permanent. be done if further dental disease is found(d) Damage to the Lingual Nerve on each side during the procedure, or to correct other of the Mandible (lower jaw). This nerve problems in my mouth. passes very close to the tongue side of the I understand that the dental treatment may lower wisdom tooth and gives feeling and include a blood transfusion. taste to that side of the tongue. This nerve I understand that if teeth are removed during is very close to the area of surgery, with a the dental treatment, that these may be slight risk of some damage to the nerve. retained for training purposes and then This may cause numbness and loss of disposed of sensitively. taste to that side of the tongue. This may I understand that a dentist other than the be temporary (6 – 12 months) or examining dentist may do the procedure. permanent. The dentist has told me that if immediate life-(e) The wisdom tooth root tip may break off in threatening events happen during the small pieces – less than 1mm - when the procedure, they will be treated accordingly. tooth is taken out. The oral surgeon/ dentist may not remove those pieces if there is a I understand that photographs or video footage chance that the nerves or other structures may be taken during my operation. These may may be damaged during removal. then be used for teaching health professionals. You will not be identified in any photo or video.(f) Damage to teeth growing tightly against the wisdom teeth during removal of the wisdom I understand that no guarantee has been made teeth. that the procedure will improve the condition, and may make my condition worse. On the basis of the above statements, I REQUEST TO HAVE THE PROCEDURE.©Queensland Health: Dental_02 Version 5: 12/2005 Page 1 of 1

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