The dentist has explained that I have the following condition: (Dentist to document in laymen’s terms)

The following dental treatment will be performed: Removal or extraction of teeth, teeth numbers:

There will be some pain and swelling following a tooth extraction. This may require pain medication. There will also be bleeding of the socket. This is usually minor and easily controlled by applying pressure.

There are some risks / complications, which include:
(a) Infection or exposure of the extraction socket (dry socket) due to loss of the clot. This may cause some pain and discomfort, and may need to be managed by the oral surgeon/ dentist.
(b) Biting of the numb lip which may cause damage after the teeth have been removed. Children should be watched closely by your parent/ guardian until the numbness wears off.
(c) Damage to the Inferior Alveolar 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. This nerve may be close to the area of surgery, and there is a risk of damage to the nerve. This may cause numbness of the lower teeth, lower lip and chin. This may be temporary (6–12 months) or permanent.
(d) Damage to the Lingual Nerve on each side of the Mandible (lower jaw). This nerve passes very close to the tongue side of the lower wisdom tooth and posterior mandibular teeth and gives feeling and taste to that side of the tongue. This nerve may be close to the area of surgery, and there is a risk of damage to the nerve. This may cause numbness and loss of
taste to that side of the tongue. This may be temporary (6–12 months) or permanent.
(e) The tooth root tip may break off in small pieces when the tooth is taken out. The dentist may not remove those pieces if there is a chance that the nerves or other structures may be damaged during removal.
(f) Damage to teeth against the wisdom teeth during removal of the wisdom tooth. Damage to teeth adjacent to any tooth being extracted. During the extraction process, crowns adjacent to the extracted tooth may be knocked off.
(g) Weakness of the jaw due to removal of the wisdom teeth. Although not likely, the jaw may break during the procedure or during the healing period.
(h) If the upper teeth are close to the sinuses, removal may cause a hole between the mouth and the sinus. This may need further surgery and referral to the oral surgeon.

The dentist has explained my dental condition and the proposed procedure. The dentist has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The dentist has also explained relevant treatment options as well as the risks of not having the procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. I was able to ask questions and raise concerns with the dentist about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand that other dental procedures may be done if further dental disease is found during the procedure, or to correct other problems in my mouth.

By signing this document, I understand the risks involved with this procedure. I release Dr. Hassan and/or his associates from any liability related to the treatment that I receive for the condition stated above.