Consent Form For Tooth Extractions

The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents or guardians) to understand and give permission for extraction treatment. Each item should be initialed after the patients (and/or their patients or guardians) have the opportunity for discussion and questions

I, the undersigned, consent to Dr. Neetu Chopra extraction of tooth number as outlined in treatment plan.

I hereby acknowledge I have given an accurate report of my past and present physical and mental health history and reported all prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollen, dust, body diseases, gum or skin reactions, abnormal bleeding, and any other conditions related to my health.

I accept and understand the purpose of the nature of the extraction procedure. I also understand what is necessary to accomplish the removal of the teeth / tooth and all alternatives to the treatment have been fully explained.

I accept and understand that if nothing is done any of the following, but not exclusive of, could occur:

  • Bone disease

  • Loss of bone

  • Gum tissue inflammation

  • Infection

  • Sensitivity

  • Looseness of teeth followed by evolution of the tooth.

  • Temporomandibular joint problems (jaw pain)

  • Headaches

  • Referred pains to the back of the neck and facial muscles.

  • Tired muscles upon chewing.

The extraction procedure has been fully explained to me, including the risks and complications involved. I have been informed of the risks and complications, the exact duration of which is undeterminable and potentially irreversible, may include but are not exclusive of

  • Pain

  • Swelling

  • Infection or discoloration

  • Numbness of the lip, tongue, chin, cheek, or teeth

  • Inflammation of the vein

  • Injury to teeth present.

  • Bone fractures

  • Sinus penetration

  • Delayed healing

  • Allergic reaction to drugs and medications

I accept and understand that this extraction can be performed under:

  • Local anesthesia/injections.

  • Oral sedation.

  • IV sedation.

  • General anesthesia

I agree not to operate a motor vehicle or any hazardous device for at least 24 hours after the extraction procedure. I accept and understand that I must be fully recovered before I can operate a motor vehicle or hazardous device.

I accept and understand there is no warranty or guarantee of any kind as to any results or cure.

I accept and understand that there is no method to accurately predict the gum and the bone healing capabilities in each patient following the extraction.

I accept and understand that excessive smoking, alcohol, or sugar may effect gum healing and may result in complications related to healing. I agree to follow all home care instructions and to show up for all examinations as instructed.

If I suffer injury of any kind as an actual and proximate result of my not following home care instructions, I hereby absolves Dr Neetu Chopra of all financial and legal liability.

I have had the opportunity to discuss the extraction procedure and have had an opportunity to ask questions. I am fully satisfied with the answers received.

I accept and understand that I have the right to seek treatment for extraction of teeth From an American Dental Association recognized specialist in Oral and Maxillofacial surgery.

If during the extraction procedure, a change in treatment is required to fulfill the complete treatment plan, including abandoning the original treatment plan if medically/professionally necessary, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand thatI have the right to designate the individual who will make such a decision.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.