EXTRACTIONS CONSENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

Step 1 of 2

Please read and initial the work to be done below, then read and sign the section at the bottom of the form.

ASK DENTIST ABOUT WHAT TOOTH NUMBER
ASK DENTIST / RECEPTIONIST / DENTAL ASSISTANT
Please ask only receptionist, dental assistant or dentist to sign this consent form

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