Child Extraction Consent - Teeth On Wheels

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

Personal Details
Parent / Guardian First Name*
Parent / Guardian Surname*
Email*
Childs First Name*
Childs Last Name*
Tooth Number/s (Office Use Only)
Consent
Parent / Guardian Consent*
- Yes
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.
Parent/Guardian Signature*
Date Signed
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Comments
This field is for validation purposes and should be left unchanged.

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