Medical Consent Forms

Tooth Extraction Consent Form: Template for Simple and Surgical Extraction

Tooth extraction is one of the most common dental procedures, yet a tooth extraction consent form is often treated as a formality rather than a genuine informed decision. Patients should understand why removal is being recommended, what the alternatives are, and the specific risks that apply to their tooth before the procedure begins.

Plain-English, ready to useFree to download — no signup or email
Create Document

Written by Mudit AgarwalFounder & Publisher · Digital marketing expert with 8 years' experienceLast updated:

Independently researched and cross-checked against the official primary sources cited on this page. Not written or reviewed by a licensed attorney or clinician. Guidance on this page is sourced from the official publications cited below — it is not a clinical review.

  • 100% freeNo paywall, no trial
  • No signupNo email required
  • PDF & WordInstant download
  • PrivateNothing leaves your browser
1

Review the guidance

Read what this consent form must cover before you fill it in.

2

Preview the template

See every field, checkbox and signature block laid out in full.

3

Download or print

Take it as a PDF or an editable Word file — free, no signup.

On this page

This page sets out an extraction consent form template distinguishing simple extraction from surgical extraction, alongside the nerve injury and dry socket risks that deserve individual explanation rather than a blanket disclaimer. It complements the wider dental treatment consent form guidance and the medical consent forms pillar.

Download the free template

Tooth Extraction Consent Form — fully formatted and ready to print or edit. No signup, no email required.

Nerve injury risk in lower wisdom tooth and molar extraction

Lower wisdom teeth and lower molars sit close to the inferior alveolar and lingual nerves, and extraction in this area carries a recognised risk of altered sensation. This risk should be disclosed specifically, matching the standard expected for oral surgery generally.

Where imaging shows a tooth root is close to the nerve canal, this should be discussed directly with the patient before they decide whether to proceed.

Tooth replacement options and alternatives to extraction

Before agreeing to extraction, a patient should be told whether root canal treatment could save the tooth instead, and what replacing an extracted tooth would involve if they choose removal.

A gap left by extraction can shift neighbouring teeth over time, so replacement options such as a bridge, implant or partial denture should be mentioned even if the patient decides not to pursue one immediately.

Aftercare instructions and reducing complication risk

Written aftercare instructions reduce the chance of dry socket and infection, and should be given alongside verbal advice at the time of extraction. Instructions typically cover avoiding smoking, drinking through a straw, and vigorous rinsing for the first 24 hours.

Patients should be told which symptoms are normal and which warrant a return visit, particularly worsening pain a few days after extraction, which often signals dry socket rather than typical post-operative discomfort.

United States

State dental boards require documented informed consent for extractions, and many states specifically expect disclosure of nerve injury risk for lower molar and wisdom tooth procedures.

United Kingdom

GDC standards require dentists to discuss alternatives, including root canal treatment, before extraction, and to name nerve injury risk where clinically relevant.

Canada

Provincial dental regulatory colleges expect written consent for extractions, with patient records and consent documentation governed by PIPEDA.

Australia

The Dental Board of Australia's guidelines require that patients understand the risks of extraction, including nerve injury, before treatment proceeds.

Frequently asked questions

What is the difference between a simple and surgical extraction on a consent form?

+

A simple extraction removes a visible tooth without cutting gum tissue, while a surgical extraction involves an incision or bone removal, carrying a higher risk of swelling and nerve involvement.

Should nerve injury risk be included for every extraction?

+

It should be included where clinically relevant, particularly for lower wisdom teeth and molars close to the inferior alveolar or lingual nerve, rather than for every extraction generally.

Can a patient choose root canal treatment instead of extraction after signing a consent form?

+

Yes, provided the tooth is still treatable. Consent should never be treated as final once given; a patient can change their mind before the procedure actually takes place.

What symptoms after extraction should prompt a return visit?

+

Worsening pain a few days after extraction, heavy or persistent bleeding, spreading swelling, or fever should prompt the patient to contact the practice promptly.

Authoritative sources

Official guidance we cross-checked this template against.

Related Consent Forms

Fill out the Tooth Extraction Consent Form online

Complete the fields below and download a finished document. Everything stays in your browser — no signup, no account, and nothing is sent to a server.

0 of 14 fields complete0%

Still required: Patient full name, Date, Patient signature (or parent/guardian if under 16), Patient signature (or parent/guardian if under 16) — date, Dentist signature, Dentist signature — date.

Patient details
Proposed extraction
Information given to the patient
Patient statement
Signatures