Dental Treatment Informed Consent Form

Dental Informed Consent Form

Tooth/Teeth Extractions
Patient Information
Name *

First Name Last Name
Age
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email
example@example.com
Is the patient minor? *

Yes No
Parent/Guardian Information
Parent/Guardian Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Dental Procedure Details
Type of Dental Procedure *

Tooth Extraction
Please confirm which tooth/teeth are to be extracted *
Please list appropriate tooth numbers
Important Information

Risks to my health if these teeth are not removed include but are not limited to:
1. Infection
2. Cyst or Tumor formation
3. Periodontal (GUM) Disease
4. Increased risk for complications if an extraction is required at a later time.

Possible complications from surgery which may have been discussed with me include but not limited to:
1. Injury to the nerves to the lower lip and tongue causing numbness which could possibly be permanent.
2. Bleeding and/or bruising which may be prolonged.
3. Dry socket.
4. Involvement of the sinus above the upper teeth.
5. Infection.
6. Decision to leave a small piece of root in the jaw when its removal would require extensive surgery and increased risk of complication.
7. Injury to adjacent teeth or fillings.
8. Unusual reaction to medications given or prescribed.
9. Women on birth control pills should use other forms of birth control while taking antibiotics.
By checking the box below, I understand that a perfect result cannot always be guaranteed. If any unforeseen conditions arise during the procedure, I request and authorize the doctor to do whatever he deems advisable to correct the condition. I agree to cooperate completely with the doctor, and will follow post operative instructions to the best of my ability for my own comfort and safety. I have had the opportunity to ask questions concerning these procedures. I consent to the surgery as described *

Confirm
Patient/Parent/Guardian Signature *

Clear
Signed Date

Month Day Year
Date
Should be Empty:

Dental Informed Consent Form

Patient Information

Parent/Guardian Information

Dental Procedure Details