Quote Template - 0Q00l0000004Bwb
                       Quote Information
Company Address GR Health Services Created Date 29/07/2020 5:51:23 PM
U17/7 Cheriton Drive
Carramar, Western Australia 6031
Australia
Prepared By Sushma Maurya Quote Number Q-00000027
Email [email protected] Patient Name Harry Redknapp
Bill To Name Mr. Harry Redknapp Phone
Bill To 23 Fraser Street, East Fremantle, Email [email protected]
Western Australia, 6158, Australia
Ship To Name Mr. Harry Redknapp
Product List Price Sales Price Quantity Total Price
Additional Extraction Requiring Surgical Removal Of A $174.35 $174.35 1 $174.35
Tooth Or Fragment
Temporary Restoration $85.00 $85.00 1 $85.00
Additional Tooth Removal (Provided On The Same Day) $82.75 $82.75 1 $82.75
Subtotal $342.10
Discount 0.00%
Total Price $342.10
Grand Total $342.10
  Quote Acceptance Information
    
Signature \signature1 {"size":"small"}\     
Name
Date \date1 {"textsize":"small"}\
INFORMED CONSENT FORM FOR EXTRACTIONS AND WISDOM TEETH REMOVAL FOR 
You have a right to be informed about your diagnosis and planned extraction/surgery so that you may make a
decision whether to  undergo a procedure after knowing the risks  and hazards.  The disclosure  is  not  meant  to
frighten or alarm you. It is simply an effort to make you better informed so we may give an informed consent to the
procedure. Please be assured that we will do our best at all  times to make healing as rapid and trouble-free as
possible. 
POSSIBLE COMPLICATIONS (may be variable in occurrence): 
Please initial each paragraph after reading. If you have any questions, please ask your doctor before initialling.
 ALL SURGERIES: 
1.  Soreness,  pain,  swelling,  bruising,  and  restricted  mouth  opening  during  healing  sometimes  related  to
swelling and muscle soreness and sometimes related to stress on the jaw joints (TMJ), especially when TMJ
problems already exists. 
2. Bleeding, usually controllable, but may be prolonged and required additional care. 
3. Drug reactions or allergies. 
4. Infection: possibly requiring additional care, including hospitalisation and additional surgery. 
5. Stretching or cracking at the corners of the mouth. Initial:\initial1
{"size":"small"}\
 ALL TOOTH EXTRACTIONS: 
1. Dry socket (delayed healing) causing discomfort a few days after extraction requiring further care. 
2. Damage to adjacent teeth or fillings. 
3. Sharp ridges or bone splinters; may require additional surgery to smooth area. 
4. Portions of tooth remaining - sometimes fine root tips break off and/or may be deliberately left in place to
avoid damage to nearby vital structures such as nerves or the sinus cavity.
Initial:\initial1
{"size":"small"}\
 UPPER TEETH: 
1 . SINUS INVOLVEMENT : Due to closeness of the roots of upper back teeth to the sinus or from a root teeth
being displaced into the sinus, a possible sinus infection and/or sinus opening may result, which may require
medication and/or later surgery to correct. 
Initial:\initial1
{"size":"small"}\
 LOWER TEETH: 
2 .   NUMBNESS :  Due to proximity of  tooth roots (especially  wisdom teeth)  and other  surgical  sites to  the
nerves, it is possible to loose function of nerves following the removal of the tooth or surgery in the area. The
lip, chin, teeth, gums, or tongue could thus feel numb/loose sensation (resembling local anaesthetic injection).
There may also be pain, loss of taste, and change in speech. This could remain for days, weeks, or possibly,
permanently. Initial:\initial1
{"size":"small"}\
3.  JAW FRACTURE: While quite rare, it is possible in difficult or deeply impacted teeth and usually requires
additional treatment, including surgery and hospitalisation. 
Initial:\initial1
{"size":"small"}\
 ANAESTHESIA: 
1. LOCAL ANAESTHESIA: 
Certain  possible  risks  exists  that,  although rare,  could  include pain,  swelling,  bruising,  infection,
nerve damage, and unexpected reactions. ________
THE ANAESTHETIC I HAVE CHOSEN FOR MY SURGERY/EXTRACTION IS: 
1. Local Anaesthesia
I have the option of having treatment under sedation the follow sedation options are available (a separate consent
form will be prepared if one is selected:
Nitrous Oxide (Happy Gas,  Oral Sedative, Intravenous (IV) Sedation and general anaesthetic (GA).
PATIENT NAME: ___________DOB:  01/09/1954____
I hereby authorise by Dentist and staff to perform the following procedures: Extractions of tooth/teeth as per my
treatment plan and to administer an anaesthetic. I understand the doctor may discover other or different conditions
that may require additional or different procedures than those planned. I authorise him/her to perform such other
procedures as he/she deems necessary in his/her professional judgment in order to complete my surgery. 
I have discussed my past medical history with my doctor and disclosed all diseases and medications and drug use. I
agree not to operate vehicles or hazardous machinery while taking prescription narcotic pain medications. 
I  have received written postoperative instructions regarding  home care,  including emergency after hour  phone
numbers.  I  understand that individual  reactions to treatment cannot be predicted, and that if  I  experience any
unanticipated reactions during or following treatment, I agree to report them to the doctor or his/her designated
agent as soon as possible. 
I have read and discussed the preceding with the doctor and believe I have been given sufficient information to give
my consent to the planned extraction/surgery. No warrantee or guarantee has been made as to the results or cure.
 I certify that I speak, read, and write English and have read and fully understand this consent form for surgery; or if
do not, I have had someone translate so that I can understand the consent form. 
All blanks were filled in prior to my initials and signature. 
\signature1 {"size":"small"}\ \date1 {"textsize":"small"}\
________________________________________ _______________________
Patient’s (or legal guardian’s) signature Date 
3 | P a g e