ד"ר איל פרייזלר

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Surgical procedure / Tooth extraction / Apicectomy

I hereby declare that I have received a detailed oral explanation from Dr.



Below: "The main treatment"

I was explained about the primary treatment, including the hoped-for outcomes, prospects, and possible alternative therapies in the circumstances of the case and the tests and treatments involved. Alternative treatment options were considered before choosing treatment. I was explained the side effects of the main treatment including: pain, discomfort, swelling, infection, sensitivity to cold and heat and limitation of opening the mouth for a limited period of time.
It has been explained to me and I understand that there is a possibility that during the course of the main treatment, it will turn out that it is necessary to change the treatment plan in whole or in part, including additional treatments that can not be expected for sure or in full, including referrals to specialist clinics.
It is clear to me the importance of providing accurate information about health status, as well as following all the instructions I will receive from the staff / attending physician, including maintaining oral hygiene, receiving all the preservative and rehabilitative treatments I will need and performing inspections as soon as I require them. I hereby give my consent to perform the main treatment. My consent is hereby also given for performing local anesthesia after I have been clarified the risks and complications of anesthesia including, damage to sensation in the tongue and / or tongue and / or chin and / or face, subcutaneous hemorrhage, swelling and restriction in mouth opening. If it is decided to perform the main treatment.



I confirm that I explained to the patient/the patient’s guardian all the aforementioned in the required details and that he/she signed the consent before me, after I was convinced that he/she fully understood my explanation:


Doctor Signature