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Information and Consent - Tooth Extraction

Patient Name: *

First Name Last Name

Date of Birth *

Month Day Year

Treatment Recommended

It is recommended that I have the following tooth / teeth extracted: # *

Reason for Recommended Extraction

Extraction is being recommended to treat the following conditions (check all that apply):

Pain Infection Decay Periodontal (Gum) Disease Broken Tooth / Teeth Tooth is Not Restorable

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.

Cost of Extraction *

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

Alternatives to Extractions *

Endodontic Treatment. Endodontic (root canal) treatment involves the removal of the nerves and other tissues from inside the tooth and filling it with an inert material. I understand that endodontic treatment is an option. Restorative Treatment. Restorative treatment can include dental restorations, crowns, and inlays/onlays. I understand that restorative treatment is an option. Periodontal (Gum) Treatment. Periodontal treatment may include root planing, gingival grafting, or other procedure. I understand that periodontal treatment is an option. No Alternative. Tooth / Teeth is / are unsalvageable and extraction is the only reasonable course of treatment

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

Patient Signature *

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Witness Name *

Witness Signature *

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Date

Email (If you want to receive the copy of submitted form.)

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