Treatment Consent Form

Before we begin your treatment, we'd like to make sure you fully understand the procedure and feel comfortable giving your consent. Please read each section carefully and ask us anything you'd like to clarify.

Section 1 — Patient Details

Patient's full name:

Date:

Section 2 — Treatment Information

Treatment being performed:

Description of the treatment (to be completed by your dentist):

Section 3 — Risks & Side Effects

Your dentist has explained the following possible risks and side effects. Please tick each one to confirm you have been informed:

Pain / discomfort

Swelling

Bleeding

Numbness

Infection

Allergic reaction

Section 4 — Your Consent

Please tick each statement to confirm your understanding and consent:

I understand the treatment and the associated risks

I have had the opportunity to ask questions and they have been answered to my satisfaction

I consent to the proposed treatment

I consent to necessary anaesthesia as part of this treatment

Section 5 — Alternative Treatments & Additional Notes

Alternative treatments discussed with the patient:

Additional notes:

Thank you for taking the time to review this form. Your trust means a great deal to us, and we're committed to making your experience as comfortable and safe as possible.

Treatment Consent Form

Section 1 — Patient Details

Section 2 — Treatment Information

Section 3 — Risks & Side Effects

Section 4 — Your Consent

Section 5 — Alternative Treatments & Additional Notes

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