Aziz Bohra, DMD, MS

13065 W. McDowell Suite A101, Avondale, Arizona 85392


Consent for Tooth Extraction

Patient Name:
Cell Phone

I hereby authorize Dr. Bohra/ Dr. Siu to administer local anesthetic and remove the following teeth :

For the following reason(s):
Periodontal disease

The consequences of not performing necessary extractions may include:

  • Continuation, growth, and/or spread of infection
  • Pain and swelling
  • Systemic infection, such as fever, sepsis, and (in rare cases) death
  • Aspiration (inhaling) of loose teeth or tooth fragments

Though rare, the following complications may occur during or after dental extractions:

  • Pain and swelling
  • Injury to neighboring teeth, restorations, or soft tissues
  • Reversible or irreversible nerve damage
  • Dry socket (a painful, noninfectious complication)
  • Infection
  • Adverse reactions to medications, anesthesia, or substances used for the extraction
  • Retained fragments of teeth in the jaw (if the risk of removal outweighs the benefit)
  • Perforation of the maxillary sinus, possibly requiring further treatment
  • In rare cases, fracture of the jaw requiring further treatment

I understand that tooth extraction is an elective procedure, and there are often alternative treatments, such as a root canal and restoration, or performing no treatment at all. My dentist has described other options (including tooth replacement) invited me to ask questions, and I am electing to proceed with the extraction.

I will follow the verbal and written postoperative instructions and return for a follow-up appointment if requested.

Patient's Signature:

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Guardian Signature:

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