Tooth Extraction Consent Form

About this form

The tooth extraction consent form is a consent forms document used by dental practices. Consent for tooth extraction covering risks such as dry socket, nerve damage, and post-op care. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 10 fields:

• Patient Name — Text
• Tooth Number / Location — Text
• Reason for Extraction — Long answer
• I understand risks include bleeding, infection, and dry socket — Multiple choice
• I understand there is a risk of nerve damage causing numbness — Multiple choice
• Anesthesia Type — Single choice
• I acknowledge post-operative instructions have been explained — Multiple choice
• Current Medications — Long answer
• Patient Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the treatment workflow, completing it with the patient after the procedure and its alternatives have been discussed. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.