Dental Consent Form
A dental consent form has to record more than agreement. It has to show the patient was told what the treatment involves, what the alternatives were, what could go wrong and what it costs - before it started.
For dental practices, orthodontists and hygienists.
Alternatives are the part that gets left out
Valid consent means a patient understood the options, including doing nothing. In practice the alternatives get explained verbally and never recorded, which is exactly the gap a complaint lands in.
So this template asks the patient to confirm, as separate ticks, that the treatment was explained, that alternatives including no treatment were discussed, that the risks were named, and that they know the cost. Each response is stored with the date and time it was submitted - which is the record, not a note saying "consented".
A record you can actually rely on
Consent that was given verbally, or on a paper form in a drawer, is consent you cannot produce when it matters. What you need is the wording they agreed to, the answers they gave, and the date - all in one place.
This template collects exactly that, and every submission is stored with its own timestamp.
Medical history before the chair, not in it
Medical history, medication and anxiety level asked at reception get rushed and under-reported. Sent with the appointment confirmation, they arrive complete, read properly, and give you the ten minutes back.
It also flags the appointments that need different planning - a sedation conversation, a longer slot, a change of technique - before the day rather than at the door.
Nothing shared, nothing tracked
The page carries no analytics, no third-party scripts and no cookie banner - there's nothing to consent to except what you're asking. For a form about consent, that matters.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Patient's full name
- Date of birth
- Email address
- Treating clinician
- Which treatment?
- Which tooth or teeth?
- Agreed cost
- The treatment has been explained to me and I have had the chance to ask questions
- The alternatives, including having no treatment, were discussed with me
- I understand the risks that were explained to me
- I understand the cost and how it will be charged
- I understand that no particular outcome has been guaranteed
- Has anything changed in your medical history or medication?
- The information I have given is accurate
More Dental forms
Questions
Does this meet our regulator's requirements?
It gives you a dated, itemised record, which is usually the substance of what's asked for - but requirements differ by country and by procedure. Check with your indemnifier and adapt the wording to your own consent process.
Should we use one form for every treatment?
Better to duplicate it per treatment type so the risks named are the real ones. Generic risk wording is the least useful sentence on a consent form.
Is this legal advice?
No. The wording is a practical starting point, not a legal document - have your own adviser check anything you rely on, especially where health, minors or money are involved.
Is a tick box a valid signature?
In many places a clear, dated, affirmative action is accepted, but it depends on your jurisdiction and what you're doing. If you need a drawn signature, print the response and sign it, or take the form as the pre-appointment record.
Can I keep a copy for the person who filled it in?
Yes - they see a confirmation on screen, and you can turn on an email so a copy of each submission lands in your inbox for your records.
Can this hold patient medical information?
Responses are stored in your account, never shared, and served over encrypted connections - but you are the data controller. Ask only what you need clinically, tell patients what you keep, and check your local rules (HIPAA, UK GDPR and similar) before using a web form for health data.
Publish your dental consent form today
Start from this template and change anything you like. Free to begin.