Dental consent form

June 20, 2011

A dental consent form, as the name suggests, is being used for initiating the dental treatments and is to be filled by the patient who has to undergo the treatment.
Sample dental consent form:

* Name of the Hospital: ______________
* Personal Information:

Name of the dentist: ________________

Name of the Patient: ________________

Date of Admission: ____/____/____

* Dental consent terms:

Are you ready for the change in your dental treatment as suggested by the doctor: __________________?

Have you understood the medicines referred for your dental cavities: ______________?

Have you done the x-ray of your teeth: __________________?

Would you like to go for root canal treatment to get rid of pain: ________________________?

If the root canal condition found serious, are you ready for the removal of your teeth: _____________________

Please mention if you are taking some other medicines to treat your teeth ache: __________________

Have you understood the full terms of periodontal loss in case of failure of treatment or any medicine reaction: __________________________?

Can we take your repose as the final dental consent decision for the above mentioned: ________________?

* Signature of the patient: _______________
* Signature of the parent if minor: _________
* Date: ___/____/____

 

Download Dental consent form in Word Format

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