Dental treatment consent template

Dental Treatment Consent

Date: Date

To: Clinic Name

I, Patient or Guardian Name, confirm that Dr Dentist Name has explained the proposed Procedure on tooth or teeth Tooth Numbers, the alternatives, the expected duration and the possible risks, such as Possible Risks.

I was able to ask questions and I consent to the procedure and to local anaesthesia. I have disclosed my health and medicines: Medicines and Conditions, and I know I may withdraw consent before treatment starts.

Signed in agreement.

Patient or Guardian: Patient or Guardian Name

Signature: Signature

Dentist: Dentist Name

Dentist Signature: Dentist Signature