Consent

Dental Treatment Consent

2 pages13 fieldsHIPAA-ready

Form preview

formisoft.com/f/dental-treatment-consent
Patient Name
Date of Birth
Treating Dentist
Procedure Description
Teeth / Areas Involved
Anesthesia Type
Select...
Risks and Complications Acknowledged
Alternative Treatments Discussed
Post-Procedure Instructions Received
Treatment Plan Consent (Multi-Visit)
I agree to the terms above
Sign here
Patient Questions Addressed
Patient Signature
Sign here
Date Signed
Submit

The Dental Treatment Consent form provides documented informed consent for dental procedures ranging from routine restorative work to complex oral surgery. Dental treatment consent has unique considerations including the variety of anesthesia options (local, nitrous oxide, IV sedation, general), the frequency of multi-visit treatment plans, and procedure-specific risks such as nerve damage, sinus communication, and prosthetic complications. This form addresses all of these in a structured, patient-friendly format.

The form captures the specific procedure or treatment plan, the teeth or areas involved using standard dental notation, and the type of anesthesia to be administered. A procedure-specific risk section covers complications relevant to the planned treatment, including infection, prolonged numbness, damage to adjacent teeth, and allergic reactions to dental materials. Patients acknowledge receipt of post-procedure care instructions and understand when to contact the office for complications. For treatment plans involving multiple visits, the form can document consent for the full sequence of planned procedures.

Designed for general dental practices, oral surgery offices, periodontal practices, endodontists, and prosthodontists. The form meets the informed consent requirements of state dental practice acts and the American Dental Association's recommended guidelines. It integrates seamlessly with dental intake workflows and can be paired with the Dental Intake form for a complete new-patient onboarding package.

What's included

  • Procedure description with tooth identification
  • Anesthesia type selection and risk disclosure
  • Procedure-specific complication acknowledgment
  • Alternative treatment documentation
  • Post-procedure care instruction receipt
  • Multi-visit treatment plan consent option
  • E-signature capture

Who uses this template

  • General dental practices for restorative and preventive procedures
  • Oral surgery offices for extractions and implant placements
  • Periodontal practices for scaling, root planing, and gum surgery
  • Endodontic offices for root canal therapy consent

All form fields

13 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Treating DentistText
Procedure DescriptionLong Text
Teeth / Areas InvolvedText
Anesthesia TypeDropdown
Risks and Complications AcknowledgedCheckbox
Alternative Treatments DiscussedCheckbox
Post-Procedure Instructions ReceivedCheckbox
Treatment Plan Consent (Multi-Visit)Consent Agreement
Patient Questions AddressedLong Text
Patient SignatureE-Signature
Date SignedDate

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