"Dental Extraction Consent Form"

Dental surgery and dental extraction, in particular, is a serious procedure that can have long-lasting consequences. Informed consent is therefore required to protect the interests of both the patient and the dentist and a dental extraction consent form allows for this consent to be released.

This Dental Extraction Consent Form we offer can help you with ideas about the risks and alternatives for surgery and post-operative care. You can download the Dental Consent Form down below.

Alternate Names:

  • Dental Consent Form;
  • Dental Treatment Consent Form;
  • Tooth Extraction Consent Form.

The form presents various possibilities that the patient faces by undergoing the surgery, as well as the after-surgery treatment and the dentist makes sure the clinic or the dentist personally has done their best to avoid a lawsuit.

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What Is a Dental Extraction Consent Form?

By providing their signature on the tooth removal consent form, the patient certifies that they have been informed about the fee involved, understand the recommended treatment, know about the risks of such treatment, and any alternatives and risks of the alternatives, as well as the consequences of doing nothing. The patient then agrees to have had all of their questions answered, and admits they have not been offered any guarantees.

The Consent Form for dental extraction usually mentions such dental conditions of non-treatment as infection, swelling, and pain. It can also include dental diseases, like periodontal disease, malocclusion, and systemic infection. The risks associated with any dental, surgical, and anesthetic procedure include, but are not limited to any of the following:

  1. Infection or inflammation.
  2. Swelling, bruising, and pain.
  3. Damage to the adjacent teeth or fillings.
  4. Drug reactions and side-effects.
  5. Bleeding that sometimes results in emergency treatment.
  6. The possibility that a small fragment of root or bone will be left in the jaw intentionally or unintentionally.
  7. Delayed healing (dry socket), which sometimes means several post-operative visits.
  8. Damage to sinuses that requires treatment at a later date.
  9. Fracture or dislocation of the jaw.
  10. Damage to the nerves during tooth removal. This damage can result in a temporary, partial, or permanent numbness of the lip, chin, tongue, or other facial areas.

As to post-operative care, the patient agrees to refrain from smoking and spitting for 3 days, as well as from drinking through a straw for 3 days. Any kind of heavy exertion is not recommended for 3 days after tooth extraction and the patient agrees to these terms by signing the form.


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Dental Extraction Consent Form
(Consent for Extraction of Teeth)
Acknowledgment of Receipt of Information. State law requires that you be given
certain information and that we obtain your consent prior to beginning any surgical
dental treatment. What you are being asked to sign is a confirmation that we have
discussed the nature and purpose of the treatment, the known risks associated with the
treatment, and the feasible treatment alternatives; that you have been given an
opportunity to ask questions; that all your questions have been answered in a
satisfactory manner. Please read this form carefully before signing it and ask about
anything that you do not understand. We will be pleased to explain.
_______________________________
_______________________________
Patient’s First Name
Patient’s Last Name
Consent for Tooth Extraction. I hereby authorize and direct ___________________
to perform surgical tooth extraction (or upon any person identified above as the
patient, for whom I am empowered to consent).
_______________________________
_______________________________
Tooth
Location
I understand that it may be necessary to place sterilized human bone matrix to help
augment the extraction socket for future dental implants, bridges, or dentures.
Extraction of teeth is an irreversible process and whether routine or difficult is a
surgical procedure. We will do everything we can to make sure your treatment is
problem-free. As in any surgery, there are some risks. These risks include but are not
limited to:
1. Swelling and or bruising and discomfort in the surgery area.
2. Stretching of the corners of the mouth resulting in cracking and bruising.
3. Possible infection requiring further treatment.
4. Dry socket – jaw pain beginning a few days after surgery, usually requiring
additional care, it is more common from lower extractions, especially wisdom
teeth.
5. Possible damage to adjacent teeth, especially those with large fillings or caps.
6. The lower back teeth are adjacent to a large nerve. Numbness or altered
sedation in the teeth, lip, tongue, and chin, due to the closeness of tooth roots
(especially wisdom teeth) to the nerves which can be bruised or injured.
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TEMPLATEROLLER.COM
Dental Extraction Consent Form
(Consent for Extraction of Teeth)
Acknowledgment of Receipt of Information. State law requires that you be given
certain information and that we obtain your consent prior to beginning any surgical
dental treatment. What you are being asked to sign is a confirmation that we have
discussed the nature and purpose of the treatment, the known risks associated with the
treatment, and the feasible treatment alternatives; that you have been given an
opportunity to ask questions; that all your questions have been answered in a
satisfactory manner. Please read this form carefully before signing it and ask about
anything that you do not understand. We will be pleased to explain.
_______________________________
_______________________________
Patient’s First Name
Patient’s Last Name
Consent for Tooth Extraction. I hereby authorize and direct ___________________
to perform surgical tooth extraction (or upon any person identified above as the
patient, for whom I am empowered to consent).
_______________________________
_______________________________
Tooth
Location
I understand that it may be necessary to place sterilized human bone matrix to help
augment the extraction socket for future dental implants, bridges, or dentures.
Extraction of teeth is an irreversible process and whether routine or difficult is a
surgical procedure. We will do everything we can to make sure your treatment is
problem-free. As in any surgery, there are some risks. These risks include but are not
limited to:
1. Swelling and or bruising and discomfort in the surgery area.
2. Stretching of the corners of the mouth resulting in cracking and bruising.
3. Possible infection requiring further treatment.
4. Dry socket – jaw pain beginning a few days after surgery, usually requiring
additional care, it is more common from lower extractions, especially wisdom
teeth.
5. Possible damage to adjacent teeth, especially those with large fillings or caps.
6. The lower back teeth are adjacent to a large nerve. Numbness or altered
sedation in the teeth, lip, tongue, and chin, due to the closeness of tooth roots
(especially wisdom teeth) to the nerves which can be bruised or injured.
©
TEMPLATEROLLER.COM
Sensation most often returns to normal, but in rare cases, the loss may be
permanent.
7. Trismus – limited jaw opening due to inflammation or swelling, most common
after wisdom tooth removal. Sometimes it is the result of jaw joint discomfort
(TMJ), especially when TMJ disease and symptoms already exist.
8. Bleeding – significant bleeding is not common, but persistent oozing can be
expected for several hours.
9. Sharp ridges or bone splinters may form later at the edge of the socket. These
may require another surgery to smooth or remove them.
10. Incomplete removal of tooth fragments – to avoid injury to vital structures such
as nerves or sinuses, sometimes small root tips may be left in place. Sinus
involvement: The roots of upper back teeth are often close to the sinus and
sometimes a piece of root can be displaced into the sinus, or an opening may
occur into the mouth which may require additional care.
11. The upper back teeth can be very close to the sinus. In rare instances, a
communication between the sinus and the extraction socket can occur. In
extremely rare circumstances a toot or part of the tooth can be pushed into the
sinus. All these situations are fully manageable.
12. Most procedures are routine and serious complications are not expected. Those,
which do occur, are most often minor and can be treated.
I hereby state that I have read and I fully understand this consent form. I have been
given an opportunity to ask any questions I might have had, that those questions have
been answered in a satisfactory manner.
_______________________________
_______________________________
Date
Signature
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