About this template
The Dental Extraction Consent Form is an essential tool for dental practices to ensure patients are fully informed about the risks, benefits, and alternatives of a tooth extraction procedure. By using this standardized digital form, clinicians can clearly communicate the nature of the surgery and the potential post-operative side effects, ensuring the patient understands the clinical necessity and recovery process.
This template is designed to streamline the informed consent process, moving away from paper-based systems to a secure, digital-first approach. It captures vital patient contact information, confirms their understanding of the procedure, and provides a space for a digital signature. Using Doc2Form to deploy this as a Google Form allows dental offices to maintain organized, time-stamped records of patient authorization, which is critical for clinical documentation and risk management. It fosters a transparent patient-provider relationship by ensuring that all necessary disclosures are presented clearly before the procedure begins.
Key features
- Standardized disclosure of procedure risks and benefits.
- Integrated digital signature field for patient authorization.
- Easily accessible on tablets or mobile devices in the clinic.
- Automatic timestamping for clinical record accuracy.
- Seamless integration with Google Drive for secure storage.
Use cases
- Routine tooth extractions and wisdom tooth removal.
- Emergency dental surgery authorizations.
- Pre-operative clinical intake for new patients.
- Documenting patient acknowledgement of post-operative care instructions.
What this form collects
- Patient Full Name (Short answer)Please enter your full legal name.
- Date of Birth (Short answer)Format: MM/DD/YYYY
- Procedure Details (Short answer)Please confirm the tooth number(s) or area of the mouth being treated.
- Informed Consent Acknowledgement (Multiple choice)I have been informed of the nature of the extraction, the risks (including infection, swelling, nerve injury, or sinus involvement), and the alternatives. I have had the opportunity to ask questions.
- Anesthesia/Sedation Consent (Multiple choice)Do you consent to the administration of local anesthesia or sedation as discussed?
- Patient Signature (Short answer)Please type your full name here to serve as your electronic signature.
- Date of Signature (Date)Enter today's date.
FAQ
Why is a digital consent form better than paper?
Digital forms are easier to store, search, and retrieve. They eliminate the risk of lost paperwork and ensure that every consent document is timestamped and securely saved in your Google Drive.
Can I customize the risks listed in this form?
Yes. Once you convert this template, you can easily edit the description fields in Google Forms to include specific risks or clinical disclosures relevant to your practice.
Is this form legally binding?
While this template provides a robust framework for informed consent, you should always consult with your local dental board or legal counsel to ensure the language meets specific regional requirements for medical authorization.
How do I handle the patient signature?
You can use a signature add-on for Google Forms or simply use the text field provided to capture the patient's full name as a formal acknowledgement of their consent.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.