Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Dental Treatment Consent
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Treating Dentist
Procedure Description
Teeth / Areas Involved
Anesthesia Type
- Local
- Regional
- General
- Sedation
- To be discussed with clinician
Risks and Complications Acknowledged
Additional details
Alternative Treatments Discussed
Post-Procedure Instructions Received
Treatment Plan Consent (Multi-Visit)
Your practice's consent wording goes here.
Signature
Date
Patient Questions Addressed
Patient Signature
Date
Date Signed
____ / ____ / ________
Dental Treatment Consent template from formisoft.com. formisoft.com/intake-templates/dental-treatment-consent