Product

Product Tour See how FormBuilder works Templates Ready-made form templates Marketplace Expert-made forms and tests Use Cases Forms for every industry Security Enterprise-grade data protection Integrations Connect with your tools Changelog Latest updates and releases
Features

Form Builder
Drag & Drop Builder Form Field Types Multi-Page Forms Conditional Logic Form Embedding

Form Analytics
Submissions Real-Time Submissions Form Analytics Email Notifications Form Scheduling

Themes
Themes White Label Team Collaboration Audit Log Assessment Mode Google Forms Import

All Features See every feature we offer
AI

AI Overview

Our AI-powered features

Cook it AI

Generate forms from text or files

Generate

Pulse AI

AI insights on your form data

Analyze

Edit AI

Rewrite and refine forms in place

Edit
Solutions

Solutions
Form Builder Build any form from scratch AI Form Builder Generate forms with AI Online Forms Create and share forms online Survey Maker Build surveys and collect feedback Quiz Maker Create graded quizzes and tests Assessment Platform Proctored exams with lockdown Appointment Scheduling Booking forms with calendar

Compare
vs Google Forms vs Typeform vs JotForm vs SurveyMonkey vs Microsoft Forms All Comparisons →
Pricing

Dental Consent

Streamline Wisdom Tooth Extraction & IV Sedation Consent

Help oral surgeons screen patients, document extraction and IV sedation risks, confirm a responsible escort, and capture informed consent online.

Use This Template Free Preview

Umber theme

formbuilder.ai/f/wisdom-tooth-extraction-iv-sedation-informed-consent-form

Wisdom Tooth Extraction & IV Sedation Informed Consent Form

Patient Full Name

· · ·

Patient Date of Birth

· · ·

Patient Phone Number

· · ·

Submit

The Wisdom Tooth Extraction and IV Sedation Informed Consent Form template gives oral surgery and dental practices a complete, digital way to prepare patients for third molar removal under IV sedation. It gathers patient and procedure details and records which wisdom teeth will be extracted. A medical history and sedation screening section covers existing conditions, known allergies, and current medications and supplements, including blood thinners and bone-density medications that can affect surgery and healing.

The form is built for oral and maxillofacial surgeons, general dentists, and sedation dentistry clinics. It walks patients through the risks of both extraction and IV sedation, with a checkbox acknowledgment for each item. It also explains alternatives such as continued monitoring, extraction under local anesthesia only, or no treatment. The form records a responsible adult escort and their phone number so you can confirm a safe ride home is arranged in advance. Patients also confirm each pre-sedation instruction individually, which helps prevent day-of-surgery delays and cancellations.

Moving consent online saves front-desk time and eliminates illegible paperwork. It also creates a clear digital record showing that patients reviewed the risks, alternatives, and instructions before treatment. Patients can complete the form from home ahead of their appointment. The final authorization section captures their agreement and whether they are signing as the patient or on the patient's behalf. Customize the risk lists, instructions, and branding to match your practice protocols and local requirements. Then share the form by link or embed it on your website in minutes.

4 Pages

19 Questions

~6min To complete

Free No credit card needed

Field types Multiple Choice ×5 Full Name ×3 Date ×2 Phone ×2 Long Text ×2 Email singlecheckbox termsandconditions Single Choice Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient & Procedure Information 5 questions

Patient & Procedure Information

1 Patient Full Name * Full Name

2 Patient Date of Birth * Date

3 Patient Phone Number * Phone

4 Email Address * Email

5 Wisdom Teeth to Be Extracted (select all that apply) * Multiple Choice

Page 2 Medical History & Sedation Screening 5 questions

Medical History & Sedation Screening

1 Do you have or have you ever had any of the following? (select all that apply) * Multiple Choice

2 Known Allergies (medications, latex, anesthetics, foods). Enter None if not applicable * Long Text

3 Current Medications & Supplements (include blood thinners and bone-density medications). Enter None if not applicable * Long Text

4 Responsible Adult Escort (must accompany you and drive you home) * Full Name

5 Escort Phone Number * Phone

Page 3 Risks, Alternatives & Pre-Sedation Instructions 4 questions

Risks, Alternatives & Pre-Sedation Instructions

1 I understand that the risks of wisdom tooth extraction may include (check each to acknowledge) * Multiple Choice

2 I understand that the risks of IV sedation may include (check each to acknowledge) * Multiple Choice

3 I understand the alternatives to this treatment, including no treatment, continued monitoring, or extraction under local anesthesia only. I also understand that declining treatment may lead to infection, cysts, gum disease, or damage to nearby teeth. * singlecheckbox

4 Pre-Sedation Instructions: check each to confirm you will comply * Multiple Choice

Page 4 Consent & Authorization 5 questions

Consent & Authorization

1 I have read and understand this consent form, have had the opportunity to ask questions, and certify that my medical information is accurate and complete. I authorize my oral surgeon and staff to extract the selected wisdom teeth under local anesthesia and IV sedation and to perform any additional treatment deemed necessary if unforeseen conditions arise. I understand that no guarantee of results has been made and that I may withdraw consent before the procedure begins. * termsandconditions

2 I am signing as * Single Choice

3 Printed Name of Person Signing * Full Name

4 Date Signed * Date

5 Signature of Patient or Parent/Legal Guardian * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.