This form must be completed correctly for your child’s tooth to be extracted by Teeth on Wheels.

  • Personal Details

  • Consent

  • I give consent for the Teeth on Wheels staff members to use Local Anaesthetic and remove tooth indicated above.

    The Teeth on Wheels staff members have informed me of any complications related to extractions and given me an after-extraction care sheet that explains how to care for the extraction site after the treatment has been completed.
  • This field is for validation purposes and should be left unchanged.