Whether you are a dentist, esthetician, dermatologist, or skincare specialist performing extractions, proper documentation is crucial.
An extraction consent form is more than just paperwork; it protects both you and your clients, keeps things transparent, and ensures legal compliance.
In this article, we will share two Extraction Consent Form templates: black and white, and colored.
These two templates are designed in Google Docs, are completely customizable, and most importantly, are 100% free to use!
Usage Note: These templates are free to use for both personal and commercial purposes. However, redistribution, resale, or uploading these templates to other websites or platforms for download or sale is strictly prohibited. Please respect the effort that went into creating these resources by using them responsibly.
How to Use the Templates
As mentioned in the intro, these templates are designed in Google Docs, so you must have a Google Account to access them.
To make a copy, simply click on the “Get this template” button, then on the “USE TEMPLATE” button. You can now access the template; you may customize the form if needed or print it as is.
Free Extraction Consent Form (B&W)
This form is designed for practitioners to make sure they obtain informed consent from the client before performing any type of extraction.
It outlines the procedure clearly, has a section where the client can check their medical history, discloses potential risks beforehand, and documents client agreement.
You can add more sections if needed. We’ve used tables to organize the data.
This Template Includes:
| Section | Fields |
|---|---|
| Patient Information | Full Name, Date of Birth, Phone Number, Email Address, Address, Emergency Contact Name & Phone |
| Procedure Details | Type of Extraction (Tooth, Blackhead, Whitehead, Cyst, Ingrown Hair, Other), Area(s) Treated, Date of Procedure, Practitioner Name |
| Medical History | Checkboxes for Allergies, Medications, Bleeding Disorder, Heart Conditions, Diabetes, Pregnancy/Nursing, Skin Conditions, Past Extractions; space for explanations |
| Consent and Acknowledgment | Risks involved, outcome disclaimer, permission for photos, acknowledgement of questions answered |
| Aftercare Instructions | Checkboxes for post-procedure care including ointment application, sun exposure avoidance, follow-up schedule, medications |
| Consent Confirmation | Patient/Guardian Signature & Date, Practitioner Signature & Date |
Free Extraction Consent Form (Color)
