Free Dental Extraction Consent Form Template

Missing clear consent can lead to confusion and mistrust in dental care. Our dental extraction consent form template helps you ensure patients fully understand the procedure, its risks, and post-operative care requirements. By using this template, you enhance patient communication, protect against liability, and foster a trusting relationship, all while complying with necessary regulations. Explore the template now to improve your practice's consent process.

When to use this form

Use this template for molar removal, impacted wisdom teeth, or emergency extractions. It helps you document risks (dry socket, infection, nerve injury), anesthesia options, and alternatives. Dentists, oral surgeons, and front-desk staff benefit: you standardize intake, reduce chairside questions, and capture e-signatures before the visit. Patients get plain-language summaries, medical history prompts, and clear aftercare. For multi-service practices, align your process with the Botox consent form and the Body piercing consent form so all consent records follow the same policy. If you need to explain privacy boundaries, your policy can mirror the Counseling confidentiality form. The result: informed decisions, fewer delays, and protection for your practice.

Must Ask Dental Extraction Consent Questions

Which tooth or teeth are planned for removal, and what is the diagnosis?
Clear identification and the reason for treatment confirm you and the patient are aligned, lowering the risk of wrong-tooth extraction. You also capture the clinical justification you may need for insurance or referrals.
Do you have any allergies to medications, latex, anesthetics, or antibiotics?
Allergy details guide safe drug and material choices during the visit. Asking now prevents adverse reactions and emergency interruptions.
What medications and supplements do you take, especially blood thinners?
Current meds affect bleeding, anesthesia, and healing. You can plan timing, dosing, and hemostatic measures before the procedure begins.
Do you have any medical conditions (heart issues, diabetes, bleeding disorders, pregnancy), or a history of bisphosphonates or head/neck radiation?
These factors change risk, antibiotic needs, and aftercare. Knowing them helps you adjust technique or consult the physician to keep the patient safe.
Do you understand the risks, benefits, alternatives (including no treatment), anesthesia options, and aftercare, and do you consent?
This confirms informed consent and sets expectations about outcomes and responsibilities. It mirrors cross-discipline best practices, like the Professional counseling informed consent form, so your documentation is consistent.

More Forms

Question		Response
Patient full legal name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Email		[email protected]
Mobile phone		555 555 5555
Emergency contact full name		John Smith
Emergency contact phone		555 555 5555
I am providing consent as		Legal guardian
Tooth or teeth to be extracted (use tooth numbers or description)		This is a test
Primary reason for extraction		Decay or infection
Anesthesia requested		Undecided
Do you authorize dental radiographs (X-rays) as needed for diagnosis and treatment?		Yes
Do you have any allergies?		Prefer not to say
List allergies and reactions		This is a test
Are you currently taking any medications, supplements, or blood thinners?		Yes
List medications and doses		This is a test
Do you have or have you ever had any of the following? (select all that apply)		Respiratory disease or asthma
Tobacco or vaping use		Current - some days
Are you pregnant or breastfeeding?		Prefer not to say
If yes, describe prior complications		This is a test
Primary physician name		This is a test
Have you had complications with dental treatment or anesthesia in the past?		No
I understand the nature of the extraction procedure and alternatives (e.g., root canal therapy, periodontal care, no treatment).		3
I acknowledge the discussed risks: pain, swelling, bleeding, infection, dry socket, delayed healing, sinus involvement (upper teeth), nerve injury (numbness/tingling), damage to adjacent teeth/restorations, jaw fracture, TMJ issues, and anesthesia reactions.		1
I authorize tooth sectioning, removal of bone, and placement of sutures if clinically needed.		No
I will follow pre- and post-operative instructions, take medications as directed, and seek care if problems arise.		3
I understand that no guarantee or warranty of results has been made.		1
Photography and imaging consent		Yes, for records and de-identified educational use
I agree to be responsible for fees not covered by insurance.		3
I consent to the extraction of the tooth/teeth listed above by the treating dentist and clinical team.		Yes
Name of person giving consent		John Smith
Relationship to patient		Legal guardian
Interpreter used to obtain consent		No
Patient or authorized representative signature		This is a test
Date signed		2025-10-15T00:00:00.000Z
Treating provider name		This is a test
Treating provider signature		This is a test
Provider signature date		2025-10-15T00:00:00.000Z

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Dental Extraction Consent Form Template

Streamline the Consent Process for Tooth Extractions

When to use this form

Must Ask Dental Extraction Consent Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Dental Extraction Consent Form Template

Streamline the Consent Process for Tooth Extractions

When to use this form

Must Ask Dental Extraction Consent Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results