Informed Consent Form

Tooth Extraction

1. PATIENT DETAILS

Patient Name

Age

Gender

Male Female

Contact Number

Email (optional)

Address

Medical History Reviewed

Yes No

If yes, attach / mention details

Allergies (if any)

Current Medications

2. PROCEDURE

Treatment / Procedure

Tooth Extraction

Tooth / Teeth Involved

Brief Explanation

The tooth will be removed from its socket in the bone. Local anesthesia will be given to ensure your comfort during the procedure.

3. BENEFITS

Relieves pain, swelling and infection.
Prevents spread of infection to other areas.
Protects adjacent teeth and supporting bone.
Helps improve oral health and function.
Makes way for proper healing or other treatment (if required).

4. RISKS & COMPLICATIONS

Mild to severe pain or discomfort during or after treatment.
Swelling, bruising and tenderness.
Bleeding (minor bleeding is normal).
Infection.
Dry socket (painful condition after healing).
Injury to adjacent teeth, gums or filling.
Numbness or tingling of lip, tongue or chin (temporary or, in rare cases, permanent).
Fracture of the tooth or jaw bone.
Need for further treatment or surgery.

5. ALTERNATIVES

Alternative Treatment Options: Root canal treatment, medication, periodontal treatment or other conservative management (if applicable).

Option of No Treatment: The problem may worsen, causing pain, swelling, infection, damage to surrounding teeth and bone loss.

Consequences of Delaying / Refusing Treatment: Increased pain, infection spread, abscess formation, damage to surrounding structures and possible tooth loss.

6. PATIENT ACKNOWLEDGEMENT

I have been informed about the nature of the procedure, its benefits, risks, possible complications, alternatives and the consequences of not having the treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

7. CONSENT

I voluntarily consent to undergo the above-mentioned procedure.

Patient / Guardian Signature

(sign after printing)

Dentist Signature

(sign after printing)

Witness Signature (if applicable)

(sign after printing)

FOR CLINIC USE — PATIENT COPY

اردو میں رضامندی کا بیان (Urdu Consent Statement)

ڈاکٹر نے مجھے میرے دانتوں کے علاج کے طریقہ کار، ممکنہ خطرات، فوائد اور متبادل علاج کے بارے میں مکمل طور پر بتایا ہے۔

تمام سوالات کے جوابات سے میں مطمئن ہوں اور اپنی مرضی سے اس علاج کے لیے رضامند ہوں۔

This document is a record of informed consent and does not replace professional legal advice. Retain a signed copy in the patient’s file.