Tooth Extraction Consent Form Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  After careful oral examination, a review of radiographs and study of dental condition, Dr.

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  no treatment, root canal therapy, filling, a crown, and/or gum treatment.

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  bruising, and stiff jaws, all of which may last for several days.

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  tongue, chin, teeth, and mouth may occur but are very rare.

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  and non-prescription, which I take, and any known drug allergies.

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  Patient Signature (print)

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  Tooth #’s to be extracted

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  Dr.

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  Patient Signature

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  Date

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  Witness Signature

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  Date

• ...and More!