Extraction Consent Form

This form is to be filled before extracting teeth

Patient Information

Patient's First Name *

Patient's Last Name *

Email (to send the filled form to you) *

Patient's DOB *

Teeth to be Extracted

Select all teeth that need to be extracted. You may choose from both baby teeth and permanent teeth.

Baby Teeth (A-T)

Permanent Teeth (1-32)

Selected Teeth

No teeth selected yet

Consent Agreement

1. I hereby authorize and request that the dentists at The Little Teeth Workshop to perform the following extractions for my child.

2. Alternatives to removal have been explained to me.

3. I am aware that an extraction involves the removal of tooth structure and the root system of that tooth.

4. I understand that complications may include but are not limited to:

Pain, swelling, or bruising after the procedure
Bleeding that may persist for several hours
Dry socket (delayed healing of the extraction site)
Infection at the extraction site
Damage to adjacent teeth or dental restorations
Sinus complications (for upper teeth)
Jaw stiffness or difficulty opening the mouth
Residual root/tooth structure being left behind requiring another procedure

5. Loss of feeling in the teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or in a rare case may be permanent, or fractured jaw.

Signature

Parent/Guardian Signature (Type Full Name) *