• Information and Consent - Tooth Extraction

  • Treatment Recommended

  • Reason for Recommended Extraction


  • This recommendation is based on my dentist’s examination and diagnosis, including any radiographic (x-ray) images taken. The treatment is intended to relieve my current symptoms and/or to permit me to continue with my dentist’s proposed course of treatment.


    What Extraction Involves

    Extraction involves completely removing a tooth from my mouth, including its roots below the surface of the gums. Some complex extractions may require cutting of the gums, removal of surrounding bone, and/or cutting the tooth into sections prior to removal.

  • I understand that I am completely responsible for the full cost of treatment regardless of whether I hold dental insurance coverage.

  • I understand that dentistry is not an exact science and that particular clinical outcomes cannot be guaranteed.


    I consent to and wish to process with the recommended treatment

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