(416) 538-8883
415 Bloor Street West Suite 300
Toronto, Ontario M5S 1X6

Surgical Removal Consent Form

I , understand the recommended treatment for my current dental needs is to have tooth (teeth) removed. I understand the cost per tooth and it is my responsibility to pay the balance per tooth upon the work being completed as Bloor Dental Health Centre is a non-assigned office. I understand I may need to receive an anesthetic. I understand I will be given specific post-operative instructions to take home with me on the day of surgery.

After your surgery, if you experience any of the following but not limited to please contact our office for an appointment upon discovery:

  1. Increased swelling on the side of the face where surgery was performed
  2. Prolonged bleeding
  3. Parasthesia (numbness) on either jaw where the extraction was done
  4. Bruising
  5. Dry socket which can be recognized by discomfort radiating into the ear, or a metallic taste in your mouth

I understand that I may experience any of the side effects mentioned above, or all, but not limited to and still wish to go ahead with surgical removal of my tooth/teeth that is recommended by and will be completed by Dr. Lawrence Freedman, a general dentist, at Bloor Dental Health Centre.

Please be advised that during surgery a root tip may fracture off in the jaw and be left behind, the jaw may fracture, or the sinus may be perforated. At Dr. Freedman's discretion you may be referred to an oral surgeon during surgery. Also, the tooth in front or behind the tooth being removed may fracture. I, understand that these are possible outcomes when having my tooth surgically removed. I also understand that at the end of the surgery if I fail to follow the specific postoperative instructions that are given to me the day of surgery that is at my own risk and Dr. Lawrence Freedman will not be held responsible.


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