Informed consent for simple and surgical tooth extractions, including specific risks such as dry socket, nerve injury, and sinus involvement, with post-operative care instructions.
The Tooth Extraction Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers dental, consent. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Tooth Extraction Consent **Practice Name:** ___________ **Provider:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Tooth / Teeth to be Extracted:** ___________ **Reason for Extraction:** ___________ --- ## Description of the Procedure A tooth extraction is the surgical removal of a tooth from its socket in the jawbone. Your provider has recommended extraction of the tooth or teeth identified above. There are two main types: **Simple extraction:** Performed under local anesthesia on a tooth that is fully erupted and visible in the mouth. The provider loosens the tooth with an instrument called an elevator and removes it with forceps. **Surgical extraction:** Required when a tooth is impacted (partially or fully beneath the gum line or bone), broken at or below the gum line, or has curved or fused roots that prevent simple extraction. The procedure involves making an incision in the gum tissue, removing bone if necessary, and sectioning the tooth for removal. Sutures are typically placed. **Type of extraction anticipated for your case:** ___________ --- ## Benefits of Extraction Extraction is recommended because it is expected to: - Eliminate pain, infection, or abscess caused by the affected tooth. - Prevent the spread of infection to adjacent teeth, bone, and surrounding tissues. - Remove a tooth that is non-restorable due to extensive decay, fracture, or bone loss. - Create space necessary for orthodontic treatment. - Remove an impacted wisdom tooth causing pain, crowding, decay, or recurrent infection. - Eliminate a source of periapical or periodontal pathology visible on radiographs. --- ## Risks and Possible Complications Tooth extraction carries specific risks you should understand before consenting. Not all complications occur; their likelihood varies by tooth position, anatomy, your medical history, and other factors.