Informed Consent for Tooth Removal (Extraction(s))

I understand that the extraction of a tooth (or teeth) has been recommended by my dentist. I have had any alternative treatment (if any) explained to me, as well as the consequences of doing nothing about my dental conditions.

I understand that non-treatment may result in, but not be limited to:

  • Infection
  • Swelling
  • Pain
  • Periodontal Disease
  • Malocclusion (damage to the way the teeth hit together)
  • Systemic disease/infection.

I understand that there are risks associated with any dental, surgical, and anesthetic procedure. These include, but are not limited to:

  • Post-operative infection or inflammation
  • Swelling, bruising, and pain
  • Damage to adjacent teeth or fillings
  • Drug reactions and side effects
  • Bleeding requiring more treatment
  • Possibility of a small fragment of root or bone being left in the jaw intentionally when its removal is not appropriate (such fragments may work their way partially out of the tissue and need to be removed later).
  • Delayed healing (dry socket) necessitating several post-operative visits
  • Damage to sinuses requiring additional treatment or surgical repair at a later date
  • Fracture or dislocation of the jaw
  • Damage to the nerves during tooth removal resulting in temporary, or possibly partial or permanent numbness or tingling of the lip, chin, tongue, or other areas


I have provided as accurate and complete a medical and personal history as possible including antibiotics, drugs, or other medications I am currently taking as well as those to which I am allergic. I will follow any and all treatment and post-treatment instructions as explained and directed to me and will permit the recommended diagnostic procedures, including X-rays.

I realize that in spite of the possible complications and risks, I do not have to proceed with the treatment should I choose not too. I am aware that the practice of dentistry is not an exact science, and I acknowledge that no guarantees, warrantees, or representations have been made to me concerning the results of the procedure.

I have read this form and have been provided with ample time to ask any and all questions I had in relation to the treatment that has been proposed. I understand and accept the potential risks and complications associated with the treatment.

I wish to proceed with the extraction(s).

I have read the information above and have had an opportunity to ask questions about the the dental treatment. I agree and consent to the dental treatment and information presented in this consent form.